Digital Health Literacy in - OAsis Home

Digital Health Literacy in Commonwealth Pacific Nations

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PALE SAU NI AND TERRY NEAL

O PEN PO LYTECHNI C O F NEW ZEALAND

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13

13

13

13

13

13

13

13

13

13

13

EDI TO R TRU DI V AN W YK

SEPTEMB ER 2012

13

13

The13 Commonwealth13 of13 Learning13 (COL)13 is13 an13 intergovernmental13 organisation13 created13 by13 Com-shy‐monwealth13 Heads13 of13 Government13 to13 encourage13 the13 development13 and13 sharing13 of13 open13 learning13 and13 distance13 education13 knowledge13 resources13 and13 technologies13

13 13 Commonwealth13 of13 Learning13 201213

copy13 201213 by13 the13 Commonwealth13 of13 Learning13 lsquoDigital13 Health13 Literacy13 in13 Commonwealth13 Pacific13 Nationsrsquo13 is13 made13 available13 under13 a13 Creative13 Commons13 Attribution-shy‐ShareAlike13 3013 Licence13 (in-shy‐ternational)13 httpcreativecommonsorglicencesby-shy‐sa3013

For13 the13 avoidance13 of13 doubt13 by13 applying13 this13 licence13 the13 Commonwealth13 of13 Learning13 does13 not13 waive13 any13 privileges13 or13 immunities13 from13 claims13 that13 it13 may13 be13 entitled13 to13 assert13 nor13 does13 the13 Commonwealth13 of13 Learning13 submit13 itself13 to13 the13 jurisdiction13 courts13 legal13 processes13 or13 laws13 of13 any13 jurisdiction13

Digital13 Health13 Literacy13 in13 Commonwealth13 Pacific13 Nations13

ISBN13 978-shy‐1-shy‐894975-shy‐57-shy‐513

13

Editor13 Trudi13 van13 Wyk13

Cover13 photo13 credit13 Ian13 PringleCommonwealth13 of13 Learning13

13

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13

13

13

13

Published13 by13

Commonwealth13 of13 Learning13 105513 West13 Hastings13 Suite13 120013 Vancouver13 British13 Columbia13 Canada13 V6E13 2E913

Telephone13 +113 60413 77513 820013 Fax13 +113 60413 77513 821013 Web13 wwwcolorg13 Email13 infocolorg13

DIGITAL13 HEALTH13 LITERACY13 IN13 COMMONWEALTH13 PACIFIC13 NATIONS13

i13

Contents

Executive summary iii

List of abbreviations vi

Introduction 1

Research methodology 1

Pacific methodology 1

Phases 3

Definition of scope and terms5

Defining ldquodigital health literacyrdquo 5

Defining ldquocommunity health workersrdquo 7

Scope9

A conceptual framework 9

Community health workers in the Pacific11

Crucial role11

Keys to success12

The interviewees 14

Technology infrastructure and access in the Pacific 16

Technology statistics 16

Variable access to technology 17

Business models and technologists 19

Community health and ICT policies in the Pacific 21

Regional digital health initiatives 21

National health plans 24


ii13

Learn and connect through ICT for health 27

Potential of ICT to enhance health 27

Potential in the Pacific 28

Distance learning 30

Digital literacy of community health workers in the Pacific 32

Health and cultural literacy in the Pacific 34

Health literacy 34

Language and culture 35

Community-relevant solutions37

A Samoan community case study40

Where international organisations such as COL might add value Recommendations42

Community-relevant projects 43


Mobile learning43

Supervision 44

Local content development 44

Conclusion44

References 46

Appendix 1 Community health workersrsquo Interview Schedule 51

Appendix 2 Other health workersrsquo Interview Schedule51

Appendix 3 Online resources and communities for Pacific health52

13


iii13

Executive summary This13 research13 had13 two13 aims13 13

bull To13 provide13 a13 broad13 overview13 of13 current13 initiatives13 in13 digital13 literacy13 in13 the13 health13 sector13 focusing13 on13 Papua13 New13 Guinea13 Solomon13 Islands13 Nauru13 Kiribati13 Tuvalu13 Vanuatu13 Samoa13 and13 Tonga13 13

bull To13 identify13 possible13 gaps13 in13 or13 needs13 for13 capability13 building13 where13 the13 Commonwealth13 of13 Learning13 (COL)13 may13 be13 able13 to13 add13 value13

The13 research13 methodology13 is13 best13 described13 as13 ldquoPartnershiprdquo13 within13 the13 New13 Zealand13 Health13 Research13 Councilrsquos13 framework13 The13 research13 used13 a13 shared13 leadership13 model13 seeking13 to13 maxi-shy‐mise13 the13 skills13 of13 both13 researchers13 and13 sought13 to13 be13 mindful13 of13 the13 councilrsquos13 guiding13 principles13 for13 forming13 and13 maintaining13 ethical13 research13 relationships13 with13 Pacific13 peoples13 The13 four13 phases13 were13

bull definition13 of13 scope13 and13 terms13

bull literature13 review13

bull interviews13 with13 the13 Pacific13 Open13 Learning13 Health13 Net13 (POLHN)13 health13 specialists13 and13 community13 health13 workers13 and13

bull analysis13 and13 report13 writing13

The13 research13 focused13 on13 the13 digital13 health13 literacy13 of13 community13 health13 workers13 mdash13 that13 is13 their13 ability13 to13 access13 understand13 compare13 evaluate13 apply13 share13 reproduce13 and13 enhance13 digital13 information13 on13 health13 so13 that13 individual13 and13 community13 health13 improves13

The13 research13 team13 determined13 that13 community13 health13 workers13 work13 through13 three13 steps13 in13 using13 digital13 information13 to13 improve13 health13 1)13 accessing13 technology13 2)13 learning13 from13 and13 con-shy‐necting13 with13 others13 and13 3)13 filtering13 translating13 and13 applying13 the13 information13 in13 their13 community13 Each13 step13 requires13 a13 different13 balance13 of13 digital13 health13 and13 cultural13 literacy13

Community13 health13 workers13 play13 a13 crucial13 role13 in13 effective13 primary13 healthcare13 models13 Pacific13 countries13 have13 been13 pursuing13 these13 initiatives13 since13 the13 late13 1970s13 with13 demonstrable13 health13 benefits13 However13 ensuring13 adequate13 financial13 and13 human13 resources13 is13 an13 ongoing13 challenge13 especially13 once13 donor13 support13 disappears13 Another13 challenge13 is13 developing13 and13 maintaining13 the13 capability13 of13 community13 health13 workers13 with13 supervision13 promoted13 as13 an13 important13 strategy13 Capability13 challenges13 are13 likely13 to13 increase13 in13 response13 to13 changing13 health13 needs13 such13 as13 the13 increase13 in13 non-shy‐communicable13 diseases13 and13 in13 urban13 health13 needs13 Each13 Pacific13 country13 needs13 culturally13 appropriate13 solutions13 developed13 with13 communities13 including13 community13 leaders13 Distance13 learning13 is13 likely13 to13 be13 part13 of13 the13 solution13 to13 capability-shy‐building13 challenges13 Communi-shy‐ties13 also13 need13 to13 be13 empowered13 to13 evaluate13 and13 continuously13 improve13 these13 co-shy‐developed13 solutions13

Technology13 infrastructure13 in13 the13 Pacific13 is13 limited13 Electricity13 standard13 mail13 and13 the13 use13 of13 printers13 and13 photocopiers13 are13 still13 challenging13 in13 some13 places13 Internet13 use13 is13 limited13 unequal13 and13 expensive13 and13 there13 is13 no13 indication13 that13 this13 situation13 will13 change13 soon13 However13 mobile13 phone13 use13 is13 growing13 markedly13 with13 Samoa13 Vanuatu13 and13 Fiji13 having13 levels13 comparable13 to13 de-shy‐veloped13 countries13 This13 suggests13 that13 piloting13 the13 use13 of13 mobile13 phones13 to13 improve13 health13 outcomes13 in13 countries13 with13 high13 mobile13 phone13 use13 may13 be13 a13 good13 place13 to13 start13


iv13

The13 research13 reviewed13 four13 regional13 initiatives13 that13 involve13 digital13 health13 mdash13 the13 Secretariat13 for13 the13 Pacific13 Communityrsquos13 Public13 Health13 Programme13 Strategic13 Plan13 Pacific13 Public13 Health13 Surveil-shy‐lance13 Network13 Pacific13 Digital13 Strategy13 and13 POLHN13 mdash13 as13 well13 as13 national13 policies13 relevant13 to13 community13 health13 and13 information13 and13 communication13 technology13 (ICT)13 The13 eight13 countries13 that13 the13 research13 focused13 on13 plus13 Fiji13 can13 be13 grouped13 into13 three13 categories13

bull ICT13 potential13 but13 not13 community13 workers13 included13 in13 national13 health13 plans13 (Nauru)13

bull Community13 workers13 but13 not13 ICT13 potential13 included13 in13 national13 health13 plans13 (Fiji13 Samoa13 Tuvalu13 and13 Vanuatu)13

bull Community13 workers13 and13 ICT13 potential13 included13 in13 national13 health13 plans13 (Kiribati13 Papua13 New13 Guinea13 Solomon13 Islands13 and13 Tonga)13

ICT13 is13 believed13 to13 have13 significant13 potential13 to13 improve13 health13 through13 better13 informing13 health13 professionals13 and13 the13 public13 and13 improving13 data13 sharing13 and13 therefore13 decision-shy‐making13 How-shy‐ever13 the13 proposed13 benefits13 such13 as13 decreased13 costs13 and13 mitigation13 of13 health13 workforce13 shortages13 are13 yet13 to13 be13 proved13 In13 the13 Pacific13 the13 Internet13 and13 mobile13 phones13 offer13 the13 poten-shy‐tial13 to13 reduce13 the13 physical13 and13 professional13 isolation13 of13 community13 health13 workers13 ICT-shy‐supported13 distance13 learning13 has13 the13 potential13 to13 help13 meet13 the13 demand13 for13 training13 community13 support13 workers13 in13 the13 Pacific13 through13 increasing13 access13 being13 affordable13 and13 supporting13 work-shy‐based13 learning13 POLHN13 is13 already13 offering13 short13 online13 courses13 to13 community13 health13 workers13 However13 research13 into13 distance13 learning13 in13 the13 Pacific13 shows13 a13 number13 of13 barriers13 to13 be13 over-shy‐come13 13

Community13 health13 workers13 in13 the13 Pacific13 appear13 to13 have13 low13 digital13 literacy13 A13 significant13 factor13 contributing13 to13 this13 appears13 to13 be13 the13 cost13 of13 and13 difficulty13 accessing13 the13 Internet13 A13 second13 factor13 is13 the13 reliance13 of13 community13 health13 workers13 on13 local13 indigenous13 holistic13 health13 informa-shy‐tion13 which13 is13 perceived13 as13 more13 important13 in13 the13 context13 of13 the13 communityrsquos13 health13 welfare13 and13 spirituality13 This13 type13 of13 knowledge13 appears13 to13 be13 unavailable13 on13 the13 Internet13 Another13 factor13 is13 the13 lack13 of13 appropriate13 and13 available13 training13 in13 the13 use13 of13 technology13

Health13 literacy13 in13 the13 Pacific13 is13 low13 which13 lowers13 demands13 on13 community13 health13 workers13 to13 increase13 their13 own13 health13 literacy13 When13 community13 health13 workers13 are13 unable13 to13 answer13 a13 health13 question13 they13 tend13 to13 approach13 others13 in13 their13 communities13 with13 greater13 health13 literacy13 first13 including13 those13 with13 traditional13 knowledge13 However13 they13 may13 seek13 information13 online13 The13 dominance13 of13 English13 as13 the13 language13 of13 the13 Internet13 limits13 the13 Internetrsquos13 potential13 in13 the13 Pacific13 but13 this13 barrier13 may13 be13 overcome13 through13 the13 development13 of13 local13 content13 Any13 at-shy‐tempts13 to13 use13 ICT13 to13 improve13 health13 outcomes13 in13 the13 Pacific13 need13 to13 be13 co-shy‐designed13 and13 developed13 with13 the13 community13 to13 meet13 their13 felt13 needs13 and13 build13 on13 the13 use13 of13 technology13 with13 which13 they13 are13 already13 comfortable13 13

The13 Samoan13 community13 case13 study13 undertaken13 as13 part13 of13 this13 research13 shows13 that13 for13 digital13 health13 to13 enable13 community13 health13 workers13 do13 their13 job13 better13 the13 following13 elements13 need13 to13 be13 present13

bull adequate13 resourcing13 which13 depends13 on13 long-shy‐term13 relationships13 between13 various13 staff13 and13 funders13

bull appropriate13 infrastructure13 including13 funding13 to13 build13 and13 sustain13 the13 infrastructure13

bull a13 model13 that13 recognises13 and13 builds13 on13 traditional13 and13 village13 ways13 of13 knowing13 and13 learning13 and13

bull training13 of13 staff13

Finally13 the13 research13 considers13 the13 implications13 of13 the13 findings13 for13 COL13 recommending13 a13 dis-shy‐tance13 learning13 project13 informed13 by13 the13 findings13 of13 the13 study13 which13 include13 13

bull the13 importance13 of13 activities13 being13 relevant13 to13 and13 supported13 by13 the13 community13


v13

bull the13 potential13 of13 distance13 learning13 to13 meet13 the13 need13 to13 train13 community13 health13 workers13 for13 the13 Pacific13 and13 other13 developing13 countries13 13

bull mobile13 phones13 rather13 than13 the13 Internet13 as13 the13 currently13 dominant13 technology13 in13 the13 Pa-shy‐cific13 13

bull the13 need13 for13 innovative13 models13 of13 supervision13 that13 can13 work13 over13 distance13 and13

bull the13 potential13 of13 local13 content13 development13 to13 address13 cultural13 and13 language13 challenges13 in13 communicating13 health13 messages13 effectively13 in13 the13 Pacific13 13


vi13

List of abbreviations 13 13

AusAID13 Australian13 Government13 Overseas13 Aid13 Programme13

CAP13 Communication13 Action13 Plan13 13

CHW13 Community13 Health13 Workers13

CSW13 Community13 Support13 Workers13

COL13 Commonwealth13 of13 Learning13

DVD13 Digital13 Versatile13 Disk13 or13 Digital13 Video13 Disk13 mdash13 An13 optical13 disk13 storage13 media13 format13

EpiNet13 Pacific13 Public13 Health13 Surveillance13 Networkrsquos13 national13 and13 regional13 multi-shy‐disciplinary13 teams13 that13 investigate13 and13 respond13 to13 disease13 outbreaks13

HealthEd13 New13 Zealand13 Ministry13 of13 Healthrsquos13 website13

HF13 High-shy‐Frequency13 (short13 wave)13 radios13 with13 modems13 used13 in13 Solomon13 Islands13

HRCNZ13 Health13 Research13 Council13 of13 New13 Zealand13 13

ICT13 Information13 and13 Communication13 Technology13

IT13 Information13 Technology13

LabNet13 Pacific13 Public13 Health13 Surveillance13 Networkrsquos13 three-shy‐tier13 network13 of13 public13 health13 laboratory13 services13 that13 confirm13 and13 identify13 disease13 outbreaks13

mDhil13 13 Indian13 company13 that13 provides13 basic13 healthcare13 information13 to13 Indian13 con-shy‐sumers13 via13 text13 messaging13 a13 mobile13 web13 browser13 and13 interactive13 digital13 content13

MoH13 Ministry13 of13 Health13

NZAID13 New13 Zealand13 Aid13 Programme13

ODL13 Open13 and13 Distance13 Learning13

OPIC13 Pacific13 Obesity13 Prevention13 in13 Communities13 Project13

PacNet13 Pacific13 Public13 Health13 Surveillance13 Networkrsquos13 listserv13 which13 provides13 an13 early13 warning13 system13 and13 communication13 tool13 for13 epidemic13 threats13

pdf13 Portable13 Document13 Format13

PFNet13 People13 First13 Network13 (Solomon13 Islands)13

PIIPP13 Pacific13 Islands13 Information13 and13 Communications13 Technologies13 Policy13 and13 Strategic13 Plan13 13

POLHN13 13 Pacific13 Open13 Learning13 Health13 Net13

RIC13 Remote13 Island13 Communication13

SMS13 Short13 Message13 Service13

SPC13 Secretariat13 of13 the13 Pacific13 Community13

VHW13 Village13 Health13 Workers13


113

Introduction The13 Commonwealth13 of13 Learning13 (COL)13 engaged13 the13 Open13 Polytechnic13 of13 New13 Zealand13 to13 conduct13 a13 research13 study13 on13 current13 initiatives13 in13 digital13 health13 literacy13 in13 the13 community13 health13 sector13 The13 study13 focused13 primarily13 on13 the13 digital13 health13 literacy13 of13 community13 health13 workers13 in13 the13 Pacific13 The13 research13 did13 not13 include13 the13 digital13 health13 literacy13 of13 13

bull formally13 trained13 health13 practitioners13 (eg13 nurses13 doctors13 and13 health13 specialists13 who13 may13 use13 technology13 to13 access13 health13 information13 and13 communities13 or13 to13 deliver13 health13 ser-shy‐vices)13 or13 13

bull individuals13 who13 access13 online13 information13 or13 communities13 to13 better13 understand13 their13 own13 health13

The13 research13 aimed13 to13 provide13 a13 broad13 overview13 of13 current13 initiatives13 in13 digital13 health13 literacy13 of13 community13 health13 workers13 in13 the13 Pacific13 focusing13 on13 Papua13 New13 Guinea13 Solomon13 Islands13 Nauru13 Kiribati13 Tuvalu13 Vanuatu13 Samoa13 and13 Tonga13 and13 to13 identify13 possible13 gaps13 in13 or13 needs13 for13 capability13 building13 where13 the13 Commonwealth13 of13 Learning13 may13 be13 able13 to13 add13 value13 13

Research methodology

PACI FI C METHO DO LO GY

The13 research13 team13 sought13 to13 use13 an13 appropriate13 Pacific13 research13 methodology13 The13 Health13 Research13 Council13 of13 New13 Zealand13 (HRCNZ)13 provides13 four13 models13 for13 health13 research13 involving13 Pacific13 practitioners13 and13 communities13 in13 New13 Zealand13 (Health13 Research13 Council13 of13 New13 Zealand13 2011)13 The13 council13 defines13 three13 as13 ldquoPacificrdquo13 The13 models13 are13 summarised13 in13 Table13 113

Table13 113 Models13 of13 Pacific13 research13

13 GOVERNANCE13 PARTNERSHIP13 RELEVANCE13 NOT13 PACIFIC13 Researchers13 Pacific-shy‐led13 (first13

named13 investigator)13 Shared13 leadership13 Pacific13 researcher13

on13 team13 None13

Capacity-shy‐building13 opportunities13

Advanced13 and13 relevant13 training13 opportunities13 13 (eg13 Pacific13 formal13 post-shy‐graduate13 qualification)13

Training13 opportunities13 for13 Pacific13 researchers13

Training13 opportunities13 13 (eg13 training13 Pacific13 interviewers)13

None13

Consultation13 Ongoing13 consultation13 (infrastructure)13

Engages13 Pacific13 community13

Demonstrated13 consultation13 13

None13

Participants13 13 Pacific13 priority13 population13

Pacific13 cohort13 Pacific13 cohort13 None13


213

Data13 design13 and13 analysis13

Pacific13 frameworks13 models13 methodologies13 re13 design13 and13 analysis13 of13 data13

Pacific-shy‐specific13 considerations13 with13 some13 Pacific13 frameworks13 or13 methodologies13

Pacific-shy‐specific13 considerations13 re13 design13 and13 analysis13

Standard13

Dissemination13 Outstanding13 culturally13 appropriate13 targeted13 and13 effective13 dissemination13

Culturally13 appropriate13 dissemination13 to13 Pacific13 communities13

Adequate13 dissemination13 to13 Pacific13 communities13

No13 effort13 formal13 publication13 assumed13 as13 only13 route13

13

The13 first13 model13 for13 working13 within13 the13 Pacific13 is13 ldquoPacific13 Governancerdquo13 in13 which13 the13 research13 is13 Pacific-shy‐led13 requires13 the13 active13 participation13 of13 Pacific13 people13 as13 agents13 of13 research13 and13 does13 not13 limit13 Pacific13 people13 to13 the13 role13 of13 research13 participants13 or13 potential13 end-shy‐users13 and13 the13 community13 owns13 the13 intrinsic13 value13 of13 the13 research13 13

The13 third13 model13 ldquoPacific13 Relevancerdquo13 is13 significant13 to13 the13 Pacific13 community13 aims13 to13 improve13 Pacific13 health13 outcomes13 adds13 to13 the13 general13 body13 of13 Pacific13 health13 research13 knowledge13 in-shy‐volves13 some13 Pacific13 participants13 mdash13 preferably13 a13 significant13 Pacific13 cohort13 that13 will13 allow13 for13 ethnic-shy‐specific13 analysis13 of13 data13 mdash13 and13 modifies13 standard13 research13 practice13 to13 ensure13 cultural13 safety13 and13 cultural13 competence13 13

The13 ldquoPacific13 Partnershiprdquo13 model13 which13 sits13 between13 ldquoPacific13 Relevancerdquo13 and13 ldquoPacific13 Govern-shy‐ancerdquo13 is13 the13 methodology13 used13 in13 this13 research13 13

The13 research13 team13 consisted13 of13 one13 Pacific13 and13 one13 non-shy‐Pacific13 researcher13 who13 used13 a13 shared13 leadership13 model13 to13 make13 the13 most13 of13 their13 combined13 skills13 and13 experience13 From13 the13 outset13 the13 team13 agreed13 on13 areas13 in13 which13 the13 Pacific13 researcherrsquos13 capability13 would13 be13 maximised13 and13 further13 developed13 He13 was13 the13 primary13 interviewer13 in13 the13 study13

Travelling13 to13 each13 country13 to13 consult13 would13 have13 created13 the13 most13 engagement13 However13 this13 was13 not13 possible13 Instead13 the13 Pacific13 researcher13 used13 a13 relational13 approach13 to13 maximise13 en-shy‐gagement13 Through13 his13 networks13 in13 the13 New13 Zealand13 ministries13 of13 Pacific13 Island13 Affairs13 Health13 and13 Education13 and13 the13 Pacific13 embassies13 in13 New13 Zealand13 he13 engaged13 with13 government13 leaders13 in13 each13 country13 The13 purpose13 was13 not13 to13 interview13 these13 people13 for13 the13 study13 but13 to13 follow13 the13 appropriate13 protocols13 and13 to13 introduce13 the13 study13 to13 them13 13

The13 study13 did13 not13 make13 use13 of13 any13 statistical13 selection13 methods13 but13 rather13 worked13 on13 relation-shy‐ship13 trails13 to13 identify13 a13 relevant13 population13 for13 the13 study13 The13 Pacific13 researcher13 invested13 significant13 time13 in13 following13 relationship13 trails13 to13 find13 suitable13 people13 to13 interview13 To13 find13 community13 health13 workers13 he13 moved13 from13 initial13 contacts13 to13 those13 they13 recommended13 being13 passed13 to13 a13 next13 person13 for13 as13 many13 steps13 as13 it13 took13 until13 he13 was13 able13 to13 contact13 a13 community13 health13 worker13 in13 a13 village13 The13 team13 also13 interviewed13 medical13 practitioners13 and13 representatives13 from13 the13 Pacific13 Open13 Learning13 Health13 Net13 (POLHN)13 to13 understand13 their13 views13 on13 the13 potential13 for13 online13 information13 and13 tools13 to13 help13 community13 health13 workers13 to13 do13 their13 job13 Towards13 the13 end13 of13 the13 study13 the13 Pacific13 researcher13 visited13 Samoa13 to13 interview13 Samoan13 medical13 practition-shy‐ers13 as13 a13 specific13 case13 study13

The13 research13 focused13 on13 eight13 countries13 Papua13 New13 Guinea13 Solomon13 Islands13 Nauru13 Kiribati13 Tuvalu13 Vanuatu13 Samoa13 and13 Tonga13 However13 the13 team13 also13 included13 Melanesia13 Micronesia13 and13 Polynesia13 to13 extend13 the13 research13 to13 more13 remote13 Pacific13 countries13 The13 team13 sought13 to13 avoid13 a13 ldquoone-shy‐size-shy‐fits-shy‐allrdquo13 approach13 13


313

Both13 team13 members13 developed13 the13 framework13 for13 analysing13 the13 data13 with13 the13 participation13 of13 the13 Pacific13 researcher13 ensuring13 that13 it13 was13 informed13 by13 a13 Pacific13 village13 lens13 At13 all13 times13 the13 team13 sought13 to13 be13 mindful13 of13 the13 HRCNZrsquos13 guiding13 principles13 for13 forming13 and13 maintaining13 ethi-shy‐cal13 research13 relationships13 with13 Pacific13 people13 These13 include13 respect13 cultural13 competency13 meaningful13 engagement13 reciprocity13 utility13 rights13 balance13 protection13 capacity13 building13 and13 participation13 (Health13 Research13 Council13 of13 New13 Zealand13 2005)13

The13 team13 selected13 appropriate13 dissemination13 methods13 based13 on13 previous13 research13 experi-shy‐ences13 Specifically13 they13 took13 into13 account13 intervieweesrsquo13 fears13 of13 not13 being13 aware13 of13 outcomes13 from13 the13 research13 and13 the13 Pacific13 researcher13 was13 able13 to13 work13 through13 these13 concerns13 along13 the13 relationship13 trail13 The13 team13 reached13 agreement13 with13 COL13 on13 suitable13 dissemination13 ap-shy‐proaches13 for13 the13 research13 once13 it13 is13 completed13 13

COL13 and13 the13 Open13 Polytechnic13 are13 both13 committed13 to13 the13 Pacific13 for13 the13 long13 term13 It13 was13 import-shy‐ant13 to13 both13 organisations13 that13 the13 research13 team13 work13 with13 significant13 people13 in13 the13 Pacific13 and13 build13 lasting13 relationships13 to13 enable13 ongoing13 and13 relevant13 outcomes13 as13 defined13 by13 Pacific13 people13

PHASES

The13 research13 project13 consisted13 of13 four13 phases13

bull Definition13 of13 scope13 and13 terms13

bull Literature13 review13

bull Interviews13 13

bull Analysis13 and13 report13 writing13

Definition of scope and terms

The13 COL13 sponsor13 and13 the13 research13 team13 met13 to13 agree13 on13 what13 was13 meant13 by13 ldquodigital13 literacy13 in13 the13 health13 sectorrdquo13 and13 the13 scope13 of13 the13 project13 After13 the13 literature13 review13 the13 team13 further13 refined13 their13 definitions13 of13 the13 terms13

Literature review

The13 literature13 review13 searched13 for13 publicly13 available13 information13 related13 to13 digital13 health13 liter-shy‐acy13 in13 the13 Pacific13 including13

bull regional13 health13 and13 digital13 strategies13

bull national13 health13 strategies13 from13 the13 eight13 countries13 of13 focus13 as13 well13 as13 that13 of13 Fiji13 (although13 not13 part13 of13 the13 Commonwealth13 a13 leader13 in13 the13 Pacific)13 and13 13

bull online13 resources13 that13 may13 offer13 relevant13 information13 for13 Pacific13 community13 health13 workers13

The13 team13 also13 searched13 peer-shy‐reviewed13 literature13 including13

bull the13 PubMed13 database13 searching13 for13 the13 terms13 (ldquoonline13 health13 informationrdquo13 OR13 ldquohealth13 literacyrdquo)13 AND13 (pacific13 OR13 africa13 OR13 ldquodeveloping13 countriesrdquo13 OR13 ldquodeveloping13 nationsrdquo13 OR13 ldquodeveloping13 worldrdquo13 OR13 ldquoless13 developedrdquo)13 13

bull the13 EBSCOHost13 and13 PubMed13 databases13 searching13 for13 the13 terms13 (ldquocommunity13 workrdquo13 OR13 ldquosocial13 workrdquo)13 AND13 ldquohealthrdquo13 AND13 (Fiji13 OR13 Papua13 New13 Guinea13 OR13 Solomon13 Islands13 OR13 Nauru13 OR13 Kiribati13 OR13 Tuvalu13 OR13 Vanuatu13 OR13 Tonga13 OR13 Western13 Samoa)13 and13

bull the13 PubMed13 database13 searching13 for13 the13 terms13 ldquoprimary13 health13 carerdquo13 AND13 (community13 OR13 health)13 AND13 (Fiji13 OR13 Papua13 New13 Guinea13 OR13 Solomon13 Islands13 OR13 Nauru13 OR13 Kiribati13 OR13 Tuvalu13


413

OR13 Vanuatu13 OR13 Tonga13 OR13 Western13 Samoa)13 and13 for13 the13 terms13 primary13 healthcare13 (organi-shy‐sation13 AND13 administration)13 subject13 heading13 AND13 (Fiji13 OR13 Papua13 New13 Guinea13 OR13 Solomon13 Islands13 OR13 Nauru13 OR13 Kiribati13 OR13 Tuvalu13 OR13 Vanuatu13 OR13 Tonga13 OR13 Western13 Samoa)13

Interviews

The13 team13 developed13 an13 initial13 framework13 to13 represent13 the13 factors13 affecting13 the13 digital13 health13 literacy13 of13 community13 health13 workers13 The13 team13 also13 assessed13 gaps13 in13 the13 information13 from13 the13 initial13 literature13 review13 They13 then13 developed13 the13 interview13 schedule13 for13 community13 health13 workers13 (Appendix13 1)13 The13 team13 overcame13 the13 challenge13 of13 contacting13 community13 health13 workers13 by13 working13 through13 existing13 relationships13 as13 discussed13 above13

The13 response13 from13 those13 initially13 approached13 was13 that13 the13 research13 was13 relevant13 and13 import-shy‐ant13 but13 that13 interviewing13 community13 health13 workers13 in13 their13 villages13 would13 have13 been13 a13 more13 appropriate13 way13 to13 work13 They13 believed13 that13 a13 face-shy‐to-shy‐face13 process13 would13 have13 better13 met13 local13 expectations13 of13 how13 to13 gain13 information13 and13 would13 have13 allowed13 the13 researchers13 to13 understand13 community13 health13 worker13 roles13 in13 their13 own13 contexts13 and13 relationships13 which13 would13 have13 been13 more13 effective13 Also13 the13 team13 struggled13 to13 find13 community13 health13 workers13 they13 could13 contact13 by13 phone13 or13 email13 from13 New13 Zealand13 especially13 in13 the13 remote13 villages13 of13 Kiribati13 Nauru13 Solomon13 Islands13 and13 Tuvalu13 Finally13 visiting13 villages13 would13 have13 enabled13 the13 team13 to13 begin13 to13 build13 long-shy‐term13 strategic13 and13 solid13 relationships13

Because13 it13 proved13 difficult13 to13 find13 community13 health13 workers13 the13 team13 in13 consultation13 with13 COL13 decided13 to13 interview13 other13 medical13 professionals13 and13 educators13 to13 gather13 their13 views13 on13 the13 research13 questions13 The13 team13 developed13 a13 second13 questionnaire13 for13 other13 health13 workers13 (Appendix13 2)13 13

The13 Pacific13 researcher13 contacted13 each13 interviewee13 by13 email13 or13 phone13 or13 in13 person13 (for13 some13 in13 Samoa)13 to13 clarify13 the13 context13 All13 interviewees13 then13 chose13 to13 reply13 to13 the13 questionnaire13 in13 writ-shy‐ing13 or13 by13 email13 rather13 than13 by13 phone13 13

The13 use13 of13 email13 and13 telephones13 to13 explain13 the13 context13 exposed13 a13 number13 of13 side13 issues13 mdash13 for13 example13 language13 and13 definition13 difficulties13 challenges13 finding13 a13 time13 when13 people13 were13 free13 to13 engage13 the13 time13 it13 took13 to13 find13 the13 ldquoright13 personrdquo13 and13 the13 time13 it13 took13 to13 explain13 the13 con-shy‐text13 of13 the13 research13 Because13 interviewees13 chose13 to13 answer13 the13 questionnaire13 in13 writing13 the13 research13 did13 not13 capture13 nuances13 and13 emotions13 and13 it13 was13 not13 possible13 to13 correct13 any13 mis-shy‐understandings13 of13 the13 questions13 However13 an13 advantage13 was13 that13 respondents13 had13 more13 time13 to13 consider13 their13 answers13 Some13 respondents13 took13 the13 opportunity13 to13 dialogue13 with13 the13 re-shy‐searcher13 and13 other13 community13 members13 for13 clarity13 or13 to13 give13 more13 information13

POLHN13 is13 a13 key13 player13 in13 building13 the13 capability13 of13 health13 professionals13 by13 distance13 in13 the13 Pa-shy‐cific13 The13 team13 interviewed13 the13 POLHN13 director13 based13 in13 Fiji13 to13 understand13 his13 perspective13 on13 the13 research13 questions13 and13 the13 issues13 in13 the13 Pacific13

Finally13 the13 team13 interviewed13 members13 of13 a13 community13 health13 initiative13 in13 Samoa13 (building13 on13 the13 Pacific13 researcherrsquos13 experience13 in13 Samoa)13 to13 more13 deeply13 understand13 the13 perceived13 poten-shy‐tial13 of13 and13 barriers13 to13 the13 use13 of13 technology13 and13 online13 resources13 and13 communities13 by13 community13 health13 workers13

Analysis and report writing

The13 team13 used13 an13 iterative13 process13 to13 continually13 refine13 their13 initial13 framework13 as13 they13 reviewed13 literature13 and13 analysed13 survey13 results13 The13 final13 framework13 provided13 the13 structure13 of13 the13 report13


513

Definition of scope and terms In13 seeking13 to13 understand13 ldquodigital13 literacy13 in13 the13 health13 sectorrdquo13 the13 research13 team13 decided13 to13 focus13 on13 the13 ldquodigital13 health13 literacyrdquo13 of13 ldquocommunity13 health13 workersrdquo13 These13 two13 terms13 are13 de-shy‐fined13 below13

DEFI NI NG ldquoDI GI TAL HEALTH LI TERACYrdquo

In13 defining13 ldquodigital13 health13 literacyrdquo13 it13 is13 necessary13 to13 first13 understand13 ldquodigital13 literacyrdquo13 and13 ldquohealth13 literacyrdquo13 13

Digital literacy

There13 are13 many13 definitions13 of13 the13 term13 ldquodigital13 literacyrdquo13 and13 these13 definitions13 overlap13 with13 other13 similar13 terms13 such13 as13 information13 literacy13 reproduction13 literacy13 and13 visual13 literacy13 It13 is13 generally13 agreed13 that13 digital13 literacy13 is13 more13 than13 the13 ability13 to13 use13 computers13 and13 access13 in-shy‐formation13 (Gilster13 199713 Jones-shy‐Kavalier13 amp13 Flannigan13 2006 Buckingham13 2006)13 13

Gilster13 (1997)13 suggested13 that13 because13 the13 Internet13 is13 ldquounfiltered13 by13 editors13 and13 open13 to13 the13 contributions13 of13 allrdquo13 the13 most13 important13 skill13 in13 digital13 literacy13 is13 the13 ability13 to13 critically13 assess13 what13 one13 finds13 online13 He13 also13 noted13 the13 importance13 of13 targeting13 onersquos13 activity13 and13 of13 search13 skills13 because13 the13 myriad13 hyperlinks13 on13 the13 Web13 give13 users13 many13 choices13 leading13 to13 inter-shy‐rupted13 flow13 and13 therefore13 interrupted13 comprehension13 13

In13 describing13 digital13 and13 visual13 literacy13 Jones-shy‐Kavalier13 and13 Flannigan13 (2006)13 concluded13 that13 digi-shy‐tal13 literacy13 is13 the13 ability13 to13 work13 within13 a13 digital13 environment13 This13 is13 more13 than13 reading13 and13 interpreting13 digital13 information13 It13 is13 the13 ability13 to13 reproduce13 data13 and13 images13 and13 to13 evaluate13 and13 apply13 new-shy‐found13 knowledge13 Similarly13 visual13 literacy13 is13 more13 than13 sorting13 and13 interpreting13 visual13 actions13 and13 symbols13 It13 is13 ldquothe13 imaginative13 ability13 to13 create13 amend13 and13 reproduce13 im-shy‐ages13 digital13 or13 notrdquo13 (and13 thus13 communicate13 information13 visually)13

Buckingham13 (2006)13 suggested13 that13 the13 term13 ldquoliteracyrdquo13 needs13 to13 mean13 more13 than13 skill13 or13 com-shy‐petence13 He13 agreed13 with13 others13 who13 include13 within13 digital13 literacy13 an13 ability13 to13 search13 information13 compare13 various13 sources13 and13 assess13 their13 relevance13 and13 authority13 However13 he13 added13 four13 more13 abilities13 13

bull Representation13 An13 ability13 to13 recognise13 that13 the13 digital13 material13 is13 only13 a13 representation13 rather13 than13 a13 direct13 reproduction13 of13 the13 world13 and13 therefore13 the13 user13 needs13 to13 evaluate13 the13 material13 by13 assessing13 the13 motivations13 of13 the13 creator13 comparing13 it13 with13 othersrsquo13 con-shy‐sidering13 whose13 voices13 are13 present13 and13 not13 present13 questioning13 its13 authority13 and13 reviewing13 it13 against13 the13 userrsquos13 own13 experience13 13

bull Language13 An13 awareness13 of13 how13 language13 works13 including13 for13 digital13 material13 how13 web-shy‐sites13 are13 structured13 and13 linked13 and13 the13 rules13 of13 online13 interactions13

bull Production13 Understanding13 who13 is13 communicating13 online13 who13 their13 audience13 is13 and13 who13 their13 communication13 targets13 are13 whether13 commercial13 bodies13 interest13 groups13 or13 individu-shy‐als13 and13

bull Audience13 Understanding13 how13 users13 are13 guided13 to13 and13 within13 sites13 as13 well13 as13 the13 differ-shy‐ent13 types13 of13 audiences13 and13 how13 they13 use13 and13 respond13 to13 the13 information13 13


613

Thus13 for13 the13 purposes13 of13 this13 study13 digital13 literacy13 can13 be13 defined13 as13 the13 ability13 to13 access13 understand13 compare13 evaluate13 apply13 share13 reproduce13 and13 enhance13 digital13 information13 using13 the13 full13 range13 of13 digital13 formats13 and13 tools13 available13 The13 ultimate13 aim13 is13 communication13 mdash13 to13 both13 understand13 and13 effectively13 pass13 on13 othersrsquo13 knowledge13 so13 that13 it13 might13 be13 evaluated13 and13 applied13

Health literacy

There13 is13 a13 link13 between13 health13 and13 literacy13 levels13 particularly13 between13 womenrsquos13 literacy13 and13 the13 health13 of13 families13 (Kickbusch13 2011)13 Kickbusch13 argued13 for13 ldquohealth13 literacyrdquo13 as13 a13 specific13 form13 of13 literacy13 ldquoWhile13 education13 and13 literacy13 are13 important13 determinants13 of13 health13 health13 literacy13 as13 a13 discrete13 form13 of13 literacy13 is13 becoming13 increasingly13 important13 for13 social13 and13 eco-shy‐nomic13 developmentrdquo13

Kickbusch13 (2011)13 quoted13 two13 definitions13 of13 health13 literacy13 The13 first13 focuses13 on13 the13 ldquoability13 to13 perform13 basic13 reading13 and13 numerical13 skills13 required13 to13 function13 in13 the13 healthcare13 environmentrdquo13 The13 second13 is13 more13 relevant13 to13 this13 study13 ldquothe13 capacity13 to13 obtain13 interpret13 and13 understand13 basic13 health13 information13 and13 services13 and13 the13 competence13 to13 use13 such13 information13 and13 services13 to13 enhance13 healthrdquo13

In13 its13 definition13 of13 health13 literacy13 Workbase13 (2011)13 illustrated13 what13 this13 might13 mean13

Health13 literacy13 includes13 how13 an13 individual13 navigates13 and13 interacts13 with13 our13 complex13 health13 system13 Health13 literacy13 includes13 peoplersquos13 expectations13 about13 health13 and13 well-shy‐being13 and13 their13 understanding13 of13 health13 messages13 medicine13 labels13 and13 nutrition13 in-shy‐formation13 as13 well13 as13 their13 ability13 to13 fill13 out13 medical13 forms13 and13 talk13 with13 their13 doctor13 13

Nutbeam13 (2000)13 like13 Kickbusch13 saw13 health13 literacy13 as13 a13 key13 to13 empowerment13 ldquoHealth13 literacy13 represents13 the13 cognitive13 and13 social13 skills13 which13 determine13 the13 motivation13 and13 ability13 of13 indi-shy‐viduals13 to13 gain13 access13 to13 understand13 and13 use13 information13 in13 ways13 which13 promote13 and13 maintain13 good13 healthrdquo13 He13 suggested13 that13 health13 literacy13 includes13 two13 other13 forms13 of13 literacy13 interactive13 and13 critical13 literacies13 Interactive13 literacy13 is13 the13 ability13 to13 combine13 reading13 and13 writing13 skills13 with13 social13 skills13 to13 gain13 meaning13 from13 different13 forms13 of13 communication13 and13 apply13 this13 meaning13 to13 various13 and13 changing13 situations13 Critical13 literacy13 the13 ability13 to13 analyse13 information13 and13 use13 it13 to13 have13 greater13 control13 over13 onersquos13 life13 also13 relies13 on13 reading13 and13 writing13 and13 social13 skills13 13

As13 with13 digital13 literacy13 health13 literacy13 is13 more13 than13 understanding13 It13 requires13 an13 ability13 to13 apply13 understanding13 so13 that13 onersquos13 health13 improves13 and13 for13 women13 in13 particular13 so13 that13 onersquos13 familyrsquos13 health13 improves13

Digital health

As13 with13 other13 new13 fields13 digital13 health13 terminology13 is13 still13 evolving13 The13 World13 Health13 Organiza-shy‐tion13 uses13 the13 term13 ldquoe-shy‐Healthrdquo13 defined13 as13 ldquothe13 cost-shy‐effective13 and13 secure13 use13 of13 information13 and13 communications13 technologies13 in13 support13 of13 health13 and13 health-shy‐related13 fields13 including13 health-shy‐care13 services13 health13 surveillance13 health13 literature13 and13 health13 education13 knowledge13 and13 re-shy‐searchrdquo13 (World13 Health13 Assembly13 2005) 13

Tele-shy‐medicine13 or13 tele-shy‐health13 is13 the13 use13 of13 information13 and13 communication13 technology13 (ICT)13 to13 diagnose13 treat13 and13 care13 for13 patients13 and13 to13 promote13 global13 health13 control13 disease13 and13 edu-shy‐cate13 about13 manage13 and13 undertake13 research13 on13 health13 Technologies13 used13 include13 satellite13 links13 dedicated13 line13 connections13 interactive13 television13 systems13 and13 Internet13 connections13 to13 deliver13 voice13 images13 elements13 of13 a13 medical13 record13 commands13 to13 a13 surgical13 robot13 and13 so13 on13 Increased13 access13 through13 covering13 distance13 is13 a13 feature13 of13 the13 various13 definitions13 (American13 College13 of13 Nurse13 Practitioners13 2011)13


713

Technologies13 offer13 tremendous13 potential13 to13 enhance13 health13 services13 including13 increasing13 ac-shy‐cess13 without13 building13 traditional13 physical13 infrastructure13 However13 according13 to13 Lewis13 Hodge13 Gamage13 and13 Whittaker13 (2011)13 it13 is13 important13 to13 understand13 the13 needs13 culture13 and13 technology13 limitations13 of13 specific13 communities13 in13 order13 to13 be13 able13 to13 design13 solutions13 that13 meet13 their13 needs13

When13 designed13 and13 implemented13 effectively13 ICT13 can13 improve13 access13 for13 geographi-shy‐cally13 isolated13 communities13 provide13 support13 for13 healthcare13 workers13 aid13 in13 data13 sharing13 provide13 visual13 tools13 linking13 population13 and13 environmental13 information13 with13 disease13 outbreaks13 and13 is13 an13 effective13 electronic13 means13 for13 data13 capture13 storage13 in-shy‐terpretation13 and13 management13 In13 this13 context13 ICT13 for13 health13 refers13 to13 any13 tool13 that13 facilitates13 the13 communication13 processing13 or13 transmission13 of13 information13 by13 electronic13 means13 for13 the13 purpose13 of13 improving13 human13 health13 13

Thus13 we13 can13 conclude13 that13 digital13 health13 is13 a13 broad13 term13 that13 describes13 the13 way13 in13 which13 ICT13 can13 enhance13 various13 parts13 of13 health13 systems13 13

Digital health literacy

Based13 on13 the13 above13 definitions13 of13 digital13 and13 health13 literacies13 and13 digital13 health13 we13 can13 define13 digital13 health13 literacy13 as13 the13 ability13 to13 access13 understand13 compare13 evaluate13 apply13 share13 re-shy‐produce13 and13 enhance13 digital13 information13 on13 health13 so13 that13 individual13 and13 community13 health13 improves13

In13 a13 practical13 sense13 this13 is13 the13 ability13 of13 health13 practitioners13 to13

bull understand13 the13 potential13 of13 online13 health13 services13 to13 support13 them13 in13 doing13 their13 job13 better13 13

bull use13 various13 technological13 tools13 to13 13

o access13 and13 understand13 online13 health13 information13 in13 a13 range13 of13 multimedia13 formats13

o search13 for13 prioritise13 and13 bookmark13 relevant13 online13 resources13 13

o search13 for13 learn13 from13 and13 participate13 in13 online13 communities13 whether13 one-shy‐to-shy‐one13 one-shy‐to-shy‐many13 or13 many-shy‐to-shy‐many13 and13

o reproduce13 and13 share13 existing13 online13 health13 resources13 to13 build13 othersrsquo13 understanding13

bull evaluate13 the13 appropriateness13 of13 what13 they13 find13 for13 their13 community13

bull apply13 selected13 relevant13 information13 in13 their13 community13 to13 improve13 health13 outcomes13 and13

bull develop13 or13 modify13 existing13 online13 health13 resources13 to13 make13 these13 easier13 for13 their13 com-shy‐munity13 to13 apply13 and13 to13 share13 with13 the13 wider13 Pacific13 and13 global13 health13 community13

For13 each13 of13 these13 skills13 individuals13 may13 have13 beginner13 intermediate13 or13 advanced13 abilities13

DEFI NI NG ldquoCO MMU NI TY HEALTH W O RK ERSrdquo

The13 Global13 Health13 Workforce13 Alliance13 (2008)13 defined13 community13 health13 workers13 as13

13 13 13 a13 variety13 of13 health13 agents13 selected13 trained13 and13 working13 in13 their13 own13 communities13 performing13 a13 diverse13 range13 of13 roles13 and13 activities13 The13 main13 advantages13 are13 that13 community13 health13 workers13 can13 be13 trained13 and13 deployed13 relatively13 quickly13 (in13 one13 year)13 they13 understand13 the13 communityrsquos13 health13 needs13 and13 they13 give13 otherwise13 unserved13 communities13 access13 to13 the13 health13 system13 13


813

Typical13 roles13 are13 promoting13 immunisation13 and13 providing13 antenatal13 care13 medical13 assistance13 at13 birth13 family13 planning13 services13 vaccinations13 treatment13 for13 acute13 respiratory13 infections13 malaria13 and13 tuberculosis13 and13 case13 management13 of13 childhood13 illness13 13

There13 are13 two13 different13 types13 of13 community13 health13 workers13 There13 are13 those13 who13 are13 formally13 recognised13 within13 the13 national13 health13 system13 and13 are13 trained13 typically13 for13 one13 year13 And13 there13 are13 voluntary13 part-shy‐time13 workers13 who13 can13 play13 a13 valuable13 health-shy‐promoting13 role13 and13 assist13 other13 community-shy‐based13 workers13 13

The13 Global13 Health13 Workforce13 Alliance13 (2008)13 stated13 that13 fully13 volunteer13 programmes13 have13 proved13 unsustainable13 It13 also13 recognised13 a13 trend13 in13 developing13 countries13 for13 health13 workers13 to13 be13 delegated13 to13 perform13 tasks13 usually13 carried13 out13 by13 others13 with13 higher13 qualifications13 This13 makes13 it13 more13 difficult13 to13 build13 a13 shared13 understanding13 among13 countries13 of13 what13 someone13 called13 a13 community13 health13 worker13 may13 be13 doing13

Consistent13 with13 the13 Global13 Workforce13 Alliance13 definition13 above13 within13 Pacific13 community13 health13 programmes13 community13 health13 workers13 may13 be13 formally13 trained13 or13 voluntary13 and13 part-shy‐time13 They13 work13 in13 a13 wide13 range13 of13 ways13 to13 ensure13 effective13 primary13 healthcare13 (Jones13 1993)13 13

In13 Vanuatu13 for13 example13 health13 workers13 approach13 the13 chiefs13 first13 which13 helps13 any13 programme13 succeed13 The13 health13 workers13 meet13 with13 key13 community13 members13 such13 as13 pastors13 councillors13 and13 representatives13 of13 womenrsquos13 groups13 to13 discuss13 health13 needs13 and13 related13 issues13 and13 agree13 priorities13 and13 action13 plans13 As13 one13 health13 worker13 quoted13 by13 Jones13 (1993)13 said13 ldquoWe13 sit13 under13 the13 banyan13 tree13 We13 need13 time13 to13 absorb13 and13 do13 something13 with13 the13 people13 while13 living13 with13 them13 Listening13 skills13 are13 important13 for13 health13 workers13 We13 work13 and13 move13 with13 the13 com-shy‐munity13 where13 they13 arerdquo13 13 As13 part13 of13 workshops13 for13 mothers13 and13 children13 some13 Vanuatu13 health13 workers13 were13 using13 innovative13 methods13 such13 as13 drama13 songs13 and13 games13 Others13 were13 using13 community13 theatre13 actively13 supported13 by13 the13 Department13 of13 Health13 13

In13 Kiribati13 community13 workers13 were13 offering13 workshops13 to13 help13 communities13 understand13 nu-shy‐trition13 and13 improve13 food13 production13 and13 cultivation13 In13 the13 Solomon13 Islands13 another13 nutrition13 project13 was13 training13 community13 workers13 about13 nutrition13 cooking13 and13 gardening13 at13 a13 special13 training13 centre13 in13 Honiara13 with13 a13 village13 kitchen13 and13 gardens13 The13 community13 workers13 could13 then13 work13 with13 their13 communities13 to13 identify13 and13 solve13 nutritional13 issues13 13

Garner13 and13 Thomason13 (1993)13 outlined13 standards13 set13 by13 the13 Papua13 New13 Guinea13 Ministry13 of13 Health13 to13 ensure13 quality13 of13 primary13 healthcare13 These13 standards13 included13 aspects13 of13 the13 com-shy‐munity13 health13 worker13 role13 such13 as13 the13 number13 of13 people13 each13 worker13 should13 support13 (eg13 500ndash1000)13 The13 health13 workerrsquos13 working13 day13 was13 defined13 as13 outpatient13 care13 from13 080013 to13 130013 care13 of13 acute13 minor13 illnesses13 evenings13 from13 180013 to13 200013 and13 being13 on13 call13 for13 serious13 illness13 at13 all13 times13 Health13 workers13 were13 also13 to13 follow13 up13 on13 mothers13 and13 children13 seen13 at13 the13 maternal13 and13 child13 health13 clinic13 promote13 family13 planning13 and13 provide13 oral13 contraceptives13 and13 injections13 The13 standards13 also13 defined13 the13 physical13 infrastructure13 for13 the13 aid13 post13 (eg13 sink13 water13 supply13 pharmacy13 and13 sterilizer)13 and13 for13 the13 community13 health13 workerrsquos13 house13 (eg13 tin13 roof13 external13 tank13 and13 latrine)13

Based13 on13 the13 above13 literature13 and13 the13 Pacific13 researcherrsquos13 experience13 in13 the13 Pacific13 this13 re-shy‐search13 defines13 community13 health13 workers13 as13 those13 who13

bull are13 in13 the13 community13 committed13 to13 working13 with13 families13 and13 providing13 health13 and13 psychosocialcultural13 interventions13 for13 better13 health13 outcomes13 13

bull have13 had13 informal13 training13 (sometimes13 formal13 in13 common13 special13 areas13 such13 as13 diabetes13 and13 stroke)13

bull have13 expertise13 in13 the13 culture13 of13 their13 community13 (ie13 language13 health13 knowledge)13


913

bull are13 well13 linked13 to13 health13 and13 education13 providers13 such13 as13 traditional13 healers13 ministers13 of13 churches13 people13 of13 status13 school13 principals13 and13 teachers13 and13 13

bull are13 sometimes13 paid13 but13 are13 often13 voluntary13

This13 research13 does13 not13 include13 the13 digital13 health13 literacy13 of13 13



SCO PE

This13 research13 aimed13 primarily13 to13 13

bull give13 a13 broad13 overview13 of13 current13 digital13 health13 literacy13 initiatives13 for13 community13 health13 workers13 in13 the13 Pacific13 focusing13 on13 Papua13 New13 Guinea13 Solomon13 Islands13 Nauru13 Kiribati13 Tuvalu13 Vanuatu13 Samoa13 and13 Tonga13 and13 13

bull identify13 possible13 gaps13 in13 or13 needs13 for13 capability13 building13 where13 COL13 may13 be13 able13 to13 add13 value13 13

Having13 decided13 to13 interpret13 the13 original13 expression13 ldquodigital13 literacy13 in13 the13 health13 sectorrdquo13 as13 ldquodigital13 health13 literacy13 of13 community13 health13 workersrdquo13 and13 having13 defined13 these13 terms13 the13 team13 identified13 the13 sub-shy‐aims13 of13 the13 research13 as13 understanding13

bull government13 policies13 to13 recognise13 the13 potential13 of13 online13 health13 services13 to13 benefit13 com-shy‐munity13 health13 workers13

bull community13 health13 workersrsquo13 and13 traditional13 healersrsquo13 access13 to13 online13 information13 and13 communities13 13

bull existing13 Pacific13 online13 health13 services13 mdash13 specifically13

o reasons13 for13 putting13 health13 information13 online13

o the13 volume13 of13 information13 and13 number13 of13 communities13 available13 online13 or13 being13 put13 online13

o the13 suitability13 of13 online13 material13 and13 communities13 for13 each13 Pacific13 group13 in13 terms13 of13 language13 and13 cultural13 appropriateness13 and13 13

bull whether13 there13 is13 any13 evidence13 of13 online13 health13 information13 or13 communities13 being13 effective13 for13 community13 health13 workers13 and13 traditional13 healers13

A conceptual framework The13 researchers13 developed13 a13 conceptual13 framework13 for13 presenting13 the13 results13 of13 the13 literature13 review13 and13 the13 analysis13 of13 the13 interviews13 The13 framework13 shown13 in13 Diagram13 113 outlines13 the13 complex13 interplay13 of13 factors13 and13 players13 affecting13 the13 digital13 health13 literacy13 of13 community13 health13 workers13 13

Community13 health13 workers13 work13 within13 a13 health13 system13 that13 determines13 what13 their13 job13 is13 This13 same13 system13 provides13 levels13 of13 support13 and13 their13 training13 and13 upskilling13 This13 has13 a13 huge13 impact13 on13 their13 motivation13 and13 satisfaction13 within13 the13 job13


1013

Diagram13 113 Framework13 for13 digital13 health13 literacy13 of13 community13 health13 workers13 13

13

13

Community13 health13 workers13 move13 through13 three13 steps13 on13 their13 way13 to13 digital13 health13 literacy13 (ie13 being13 able13 to13 access13 understand13 compare13 evaluate13 apply13 share13 reproduce13 and13 en-shy‐hance13 digital13 information13 on13 health13 so13 that13 individual13 and13 community13 health13 improve)13 The13 three13 steps13 each13 requiring13 a13 different13 balance13 of13 literacies13 are13

Gain13 access13 to13 technology13 and13 information13 Learn13 and13 connect13 Filter13 translate13 and13 apply13

First13 health13 workers13 need13 ldquoaccessrdquo13 to13 suitable13 technology13 and13 information13 second13 they13 need13 to13 understand13 and13 use13 it13 to13 ldquolearn13 and13 connectrdquo13 with13 others13 and13 finally13 they13 need13 to13 be13 able13 to13 take13 what13 they13 have13 learned13 and13 ldquofilter13 translate13 and13 applyrdquo13 it13 in13 a13 way13 that13 will13 improve13 health13 outcomes13 for13 their13 communities13 13

For13 the13 first13 step13 ldquoaccessrdquo13 community13 health13 workers13 need13 a13 certain13 level13 of13 digital13 literacy13 to13 be13 able13 to13 use13 various13 technologies13 and13 access13 the13 online13 world13 mdash13 both13 resources13 and13 commu-shy‐nities13 They13 also13 need13 to13 understand13 how13 linking13 to13 this13 online13 world13 might13 help13 them13 do13 their13 job13 better13 and13 therefore13 be13 motivated13 to13 do13 it13 13

For13 this13 step13 to13 be13 possible13 a13 suitable13 technology13 infrastructure13 needs13 to13 be13 in13 place13 In13 part13 this13 infrastructure13 relies13 on13 national13 policies13 and13 in13 the13 Pacific13 this13 includes13 the13 priorities13 and13 policies13 of13 intergovernmental13 agencies13 It13 also13 requires13 sustainable13 business13 models13 operated13 by13 business13 people13 who13 can13 make13 them13 work13 and13 supported13 by13 capable13 technologists13 13

For13 the13 second13 step13 ldquolearn13 and13 connectrdquo13 the13 digital13 literacy13 level13 of13 community13 health13 workers13 remains13 important13 In13 the13 first13 step13 ldquoaccessrdquo13 the13 knowledge13 and13 skills13 for13 accessing13 technolo-shy‐gies13 and13 information13 are13 necessary13 for13 motivation13 In13 the13 second13 step13 ldquolearn13 and13 connectrdquo13 health13 workers13 experience13 both13 the13 value13 of13 using13 the13 technology13 and13 a13 level13 of13 success13 (ie13 they13 are13 able13 to13 search13 for13 and13 find13 relevant13 resources13 and13 bookmark13 them13 for13 ongoing13 use13 and13 to13 find13 and13 participate13 in13 relevant13 communities)13 Ideally13 this13 level13 of13 digital13 literacy13 can13 extend13 to13 using13 various13 tools13 that13 support13 online13 resource13 creation13 such13 as13 blogging13 and13 video13 or13 image13 sharing13 to13 contribute13 Pacific-shy‐specific13 resources13 to13 the13 global13 community13 which13 can13 then13 be13 available13 for13 other13 Pacific13 workers13 13


1113

However13 ldquolearn13 and13 connectrdquo13 also13 requires13 a13 basic13 level13 of13 health13 literacy13 so13 that13 community13 health13 workers13 can13 assess13 the13 relevance13 of13 and13 prioritise13 the13 resources13 and13 communities13 avail-shy‐able13 online13 and13 then13 determine13 how13 to13 apply13 the13 learning13 in13 their13 communities13 Health13 literacy13 also13 allows13 health13 workers13 to13 confidently13 engage13 with13 and13 contribute13 to13 online13 communities13 Potentially13 the13 health13 worker13 could13 also13 help13 others13 in13 the13 community13 learn13 and13 connect13

Finally13 ldquolearn13 and13 connectrdquo13 relies13 on13 the13 global13 community13 having13 created13 relevant13 online13 re-shy‐sources13 and13 active13 online13 communities13 In13 this13 context13 the13 framework13 uses13 the13 term13 ldquoonlinerdquo13 recognising13 that13 the13 resources13 and13 communities13 may13 be13 created13 for13 and13 accessed13 by13 other13 de-shy‐vices13 such13 as13 radio13 television13 and13 mobile13 phones13 rather13 than13 being13 limited13 to13 the13 Internet13 The13 Internet13 increasingly13 intersects13 with13 these13 devices13 mdash13 for13 example13 through13 electronic13 files13 developed13 for13 radio13 and13 television13 also13 being13 made13 available13 on13 the13 Internet13 to13 enable13 user13 control13 over13 time13 and13 place13 of13 access13 and13 mobile13 devices13 enabling13 users13 to13 be13 informed13 and13 communicate13 via13 the13 Internet13

The13 final13 step13 is13 ldquofilter13 translate13 and13 applyrdquo13 Community13 health13 workers13 play13 a13 crucial13 role13 in13 filtering13 out13 irrelevant13 learning13 from13 the13 global13 community13 and13 translating13 and13 applying13 the13 relevant13 learning13 in13 their13 local13 context13 To13 do13 this13 they13 need13 health13 literacy13 in13 order13 to13 under-shy‐stand13 health-shy‐specific13 information13 and13 how13 to13 apply13 it13 from13 a13 health13 perspective13 and13 cultural13 literacy13 in13 order13 to13 apply13 it13 appropriately13 to13 the13 health13 needs13 in13 their13 community13 They13 also13 need13 cultural13 literacy13 to13 translate13 the13 predominantly13 English13 and13 Western13 content13 for13 their13 communities13 especially13 until13 their13 technology13 infrastructure13 and13 digital13 literacy13 enable13 them13 to13 create13 culturally13 appropriate13 materials13 in13 their13 own13 languages13

An13 assumption13 supported13 by13 the13 literature13 reviewed13 by13 the13 researchers13 is13 that13 community13 health13 workers13 who13 are13 better13 informed13 and13 better13 connected13 will13 contribute13 to13 enhanced13 health13 outcomes13 mdash13 in13 other13 words13 healthier13 communities13 13

Community health workers in the Pacific

CRU CI AL RO LE

For13 low-shy‐13 and13 middle-shy‐income13 countries13 including13 those13 in13 the13 Pacific13 increasing13 the13 number13 of13 competent13 community13 health13 workers13 is13 the13 key13 to13 achieving13 improved13 health13 outcomes13 as13 quickly13 as13 possible13 (Global13 Health13 Workforce13 Alliance13 2008) In13 197713 a13 series13 of13 South13 Pacific13 seminars13 promoted13 a13 village-shy‐based13 approach13 to13 primary13 healthcare13 (World13 Health13 Organization13 2008)13 In13 Fiji13 community13 health13 workers13 were13 per-shy‐ceived13 to13 be13 integral13 to13 the13 success13 of13 such13 a13 model13 and13 the13 Ministry13 of13 Health13 established13 these13 roles13 and13 associated13 training13 programmes13 (Negin13 Roberts13 amp13 Lingam13 2011)13 13

A13 major13 component13 of13 the13 village-shy‐based13 model13 was13 the13 training13 of13 Community13 Health13 Workers13 (CHW)13 in13 mixed13 Indo-shy‐Fijian13 communities13 and13 Village13 Health13 Workers13 (VHWs)13 in13 every13 Fijian13 village13 Communities13 nominated13 a13 local13 person13 to13 become13 the13 CHWVHW13 and13 that13 person13 was13 then13 trained13 by13 the13 Ministry13 of13 Health13 through13 an13 intensive13 six-shy‐week13 programme13 followed13 by13

organised13 in-shy‐service13 training13 in13 many13 cases13 the13 community13 committed13 to13 supporting13 the13 CHWVHW13 either13 with13 cash13 or13 with13 in-shy‐kind13 contributions13 such13 as13 planting13 or13 fishing13 on13 his13 or13 her13 behalf13 Interviewees13 affirmed13 that13 the13 CHWVHW13 were13 ldquothe13 backbone13 of13 [primary13 health-shy‐

care]13 the13 interface13 between13 health13 and13 the13 communityrdquo13 (Negin13 et13 al13 2011) Health13 outcomes13


1213

significantly13 improved13 The13 infant13 mortality13 rate13 and13 maternal13 mortality13 ratio13 declined13 dramati-shy‐cally13 and13 immunisation13 rates13 increased13 Despite13 this13 success13 in13 the13 late13 1980s13 the13 use13 of13 rural13 health13 centres13 in13 Fiji13 dropped13 markedly13 Contributing13 factors13 were13 a13 perception13 that13 primary13 healthcare13 ldquohad13 been13 accomplished13 suc-shy‐cessfullyrdquo13 the13 end13 of13 external13 funding13 lack13 of13 government13 strategy13 and13 commitment13 domestic13 instability13 and13 changing13 culture13 in13 Fijian13 villages13 Spending13 on13 rural13 nursing13 stations13 was13 halved13 between13 198313 and13 199113 and13 in13 199713 the13 Fijian13 Ministry13 of13 Health13 stopped13 reporting13 spending13 on13 rural13 nursing13 stations13 as13 a13 separate13 budget13 line13 item13 Since13 199013 the13 maternal13 mortality13 ratio13 in13 Fiji13 has13 increased13 and13 there13 has13 been13 no13 progress13 against13 other13 key13 health13 indicators13 In13 200713 interviewees13 estimated13 that13 only13 60ndash7013 per13 cent13 of13 Fijian13 villages13 now13 have13 a13 village13

health13 worker13 (Negin13 et13 al13 2011)13

In13 200813 a13 visit13 by13 one13 of13 the13 researchers13 to13 Natogadravu13 the13 first13 village13 in13 Fiji13 to13 adopt13 com-shy‐munity13 health13 initiatives13 which13 had13 remained13 committed13 to13 primary13 healthcare13 identified13 ongoing13 progress13 2013 years13 after13 the13 initiative13 began13 (World13 Health13 Organization13 2008)13 Those13 interviewed13 commented13 that13 fewer13 people13 were13 sick13 or13 dying13 and13 villagers13 could13 be13 treated13 for13 minor13 ailments13 locally13 rather13 than13 having13 to13 travel13 to13 Suva13 The13 role13 of13 health13 workers13 was13 also13 seen13 as13 important13 ldquoThere13 are13 health13 workers13 in13 almost13 every13 village13 but13 those13 places13 that13 donrsquot13 have13 village13 health13 workers13 are13 left13 behind13 because13 they13 are13 the13 ones13 who13 educate13 peo-shy‐ple13 on13 primary13 health13 carerdquo13 (World13 Health13 Organization13 2008)13

K EYS TO SU CCESS

However13 the13 Fijian13 story13 also13 showed13 some13 challenges13 for13 the13 model13 A13 community13 health13 workerrsquos13 impact13 was13 affected13 by13 the13 level13 of13 operational13 support13 from13 the13 community13 enthu-shy‐siasm13 for13 training13 of13 the13 local13 doctor13 and13 the13 Ministry13 of13 Healthrsquos13 ongoing13 provision13 of13 medical13 supplies13 Without13 this13 support13 community13 health13 workers13 tended13 to13 fall13 away13 or13 lose13 commit-shy‐ment13 13

Two13 keys13 to13 the13 success13 of13 Natogadravursquos13 high-shy‐quality13 primary13 healthcare13 were13 perceived13 to13 be13 strong13 leadership13 and13 active13 participation13 by13 all13 community13 members13 Natogadravu13 chief13 Semi13 Matalau13 talked13 about13 the13 role13 of13 the13 village13 development13 committee13 in13 achieving13 improved13 health13 and13 living13 conditions13 13

If13 the13 committee13 comes13 up13 with13 a13 suitable13 development13 idea13 for13 the13 village13 we13 discuss13 it13 and13 then13 call13 a13 village13 meeting13 where13 everyone13 can13 take13 part13 including13 our13 elders13 who13 have13 the13 final13 say13 on13 most13 occasions13 So13 it13 is13 more13 of13 a13 community13 decision13 than13 the13 committee13 taking13 the13 decision13 themselves13 13 13 13 13

Sometimes13 the13 development13 of13 primary13 healthcare13 is13 not13 sustainable13 in13 vil-shy‐lages13 when13 the13 village13 chief13 might13 move13 away13 for13 employment13 So13 they13 have13 to13 pick13 another13 village13 head13 and13 it13 slows13 the13 development13 of13 primary13 health-shy‐care13 in13 the13 village13 13 13 13

We13 found13 many13 of13 the13 villages13 we13 went13 to13 have13 no13 village13 committees13 and13 they13 are13 left13 with13 very13 poor13 health13 standards13 compared13 to13 the13 villages13 that13 have13 proper13 committees13 to13 make13 decisions13 and13 manage13 their13 village13 13 13 13 (World13 Health13 Organization13 2008)13

Negin13 et13 al13 (2011)13 proposed13 several13 other13 factors13 as13 being13 key13 for13 Fiji13 returning13 to13 an13 effective13 primary13 healthcare13 model13 and13 the13 associated13 improved13 health13 outcomes13 The13 first13 echoes13 the13 experience13 of13 Natogadravu13 mdash13 that13 is13 community13 models13 appropriate13 for13 Fiji13 rather13 than13 im-shy‐ported13 external13 models13 Secondly13 Fiji13 needs13 new13 models13 that13 consider13 the13 non-shy‐communicable13


1313

disease13 challenges13 facing13 it13 and13 that13 can13 meet13 the13 continuing13 rural13 health13 needs13 as13 well13 as13 growing13 urban13 health13 needs13 Finally13 adequate13 financial13 and13 human13 resources13 are13 required13

A13 Solomon13 Islands13 study13 investigated13 why13 many13 who13 had13 been13 trained13 as13 village13 health13 work-shy‐ers13 to13 provide13 part-shy‐time13 basic13 healthcare13 were13 leaving13 their13 jobs13 (Chevalier13 Lapo13 OrsquoBrien13 amp13 Wiezerba13 1993)13 Between13 197813 and13 199313 nearly13 half13 the13 workers13 had13 left13 their13 jobs13 The13 two13 greatest13 contributing13 factors13 were13 training13 before13 the13 age13 of13 2013 and13 irregular13 payment13 Older13 married13 trainees13 were13 more13 likely13 to13 stay13 in13 the13 role13 Other13 reasons13 for13 leaving13 were13 the13 level13 of13 remuneration13 community13 pressure13 to13 have13 a13 nursersquos13 aid13 rather13 than13 a13 village13 health13 worker13 in13 the13 role13 and13 changing13 family13 commitments13 following13 marriage13 The13 health13 worker13 training13 enabled13 some13 to13 then13 train13 to13 be13 a13 nurse13

Another13 study13 sought13 to13 understand13 the13 clinical13 competency13 of13 community13 health13 workers13 in13 a13 remote13 province13 of13 Papua13 New13 Guinea13 one13 to13 four13 years13 after13 they13 completed13 their13 basic13 train-shy‐ing13 (Ashwell13 amp13 Freeman13 1995)13 After13 this13 relatively13 short13 period13 only13 one13 third13 of13 the13 graduates13 (24)13 were13 still13 working13 in13 the13 province13 Nearly13 all13 of13 them13 maintained13 their13 know-shy‐ledge13 competency13 but13 only13 6213 per13 cent13 maintained13 their13 clinical13 competency13 The13 study13 showed13 that13 community13 health13 workers13 employed13 at13 a13 health13 subcentre13 used13 40ndash5013 per13 cent13 of13 their13 skills13 whereas13 those13 employed13 at13 a13 district13 health13 centre13 or13 hospital13 used13 only13 20ndash3013 per13 cent13 of13 their13 skills13 The13 authors13 concluded13 that13 the13 community13 health13 workers13 were13 not13 being13 fully13 utilised13 and13 were13 not13 being13 given13 the13 opportunity13 to13 practise13 their13 clinical13 skills13 The13 authors13 recommended13 ongoing13 clinical13 supervision13 and13 in-shy‐service13 training13 to13 achieve13 the13 origi-shy‐nal13 goal13 of13 improved13 access13 to13 primary13 healthcare13 for13 rural13 communities13 13

A13 review13 of13 an13 in-shy‐service13 training13 for13 community13 health13 nurses13 project13 in13 Fiji13 also13 noted13 that13 the13 community13 nurses13 despite13 being13 in13 their13 roles13 for13 a13 combined13 mean13 range13 of13 four13 to13 six13 years13 were13 all13 at13 the13 lowest13 level13 of13 the13 nursing13 profession13 (Fiji13 Ministry13 of13 Health13 2011)13 The13 report13 expressed13 concern13 that13 community13 nurses13 who13 wish13 to13 progress13 in13 their13 careers13 may13 believe13 that13 they13 need13 to13 leave13 the13 community13 health13 profession13 to13 achieve13 this13

Another13 study13 in13 Papua13 New13 Guinea13 examined13 the13 competence13 of13 nurses13 and13 village13 health13 workers13 to13 accurately13 assess13 acute13 respiratory13 infection13 (Brewster13 Pyakalyia13 amp13 OrsquoConnell13 1993)13 Health13 workers13 were13 significantly13 less13 able13 than13 nurses13 to13 accurately13 assess13 the13 infec-shy‐tion13 The13 health13 workers13 relied13 more13 on13 guidelines13 given13 during13 training13 (ie13 respiratory13 rate13 and13 rigid13 protocols)13 than13 on13 clinical13 sense13 as13 the13 nurses13 did13 The13 authors13 suggested13 regular13 on-shy‐site13 clinical13 supervision13 of13 nurses13 and13 community13 health13 workers13 at13 health13 centres13 to13 ensure13 the13 success13 of13 the13 acute13 respiratory13 infection13 programme13

Similarly13 Garner13 and13 Thomason13 (1993)13 concluded13 that13 the13 key13 elements13 for13 enabling13 primary13 health13 workers13 in13 Papua13 New13 Guinea13 to13 support13 high-shy‐quality13 healthcare13 were13 clear13 perform-shy‐ance13 guidelines13 appropriate13 resources13 and13 training13 and13 supportive13 supervision13

Clearly13 in13 199313 supervision13 of13 community13 health13 workers13 was13 seen13 as13 an13 important13 way13 to13 improve13 primary13 healthcare13 in13 Papua13 New13 Guinea13 Ten13 years13 later13 very13 little13 supervision13 was13 being13 provided13 in13 Papua13 New13 Guinea13 Clements13 Streefland13 and13 Malau13 (2007)13 attributed13 this13 to13 ldquoa13 deep13 cultural13 andor13 attitudinal13 discomfort13 with13 the13 process13 for13 both13 supervisor13 and13 super-shy‐visee13 When13 supervision13 occurred13 it13 was13 not13 effective13 in13 improving13 staff13 performancerdquo13 They13 concluded13 that13 the13 traditional13 and13 supportive13 models13 are13 not13 working13 and13 suggested13 the13 de-shy‐velopment13 of13 culturally13 appropriate13 solutions13 They13 also13 noted13 that13 in13 the13 West13 there13 tends13 to13 be13 a13 ldquosupervisorrdquo13 who13 is13 onsite13 at13 a13 rural13 health13 centre13 and13 has13 the13 necessary13 skills13 in13 contrast13 to13 an13 external13 supervisor13 visit13 which13 is13 likely13 to13 be13 seen13 as13 threatening13 and13 lacking13 the13 neces-shy‐sary13 understanding13 (In13 the13 context13 of13 this13 research13 it13 is13 interesting13 to13 consider13 the13 potential13 of13 technology13 to13 enable13 a13 new13 model13 of13 supervision13 which13 may13 be13 culturally13 appropriate13 and13 may13 enable13 more13 connection13 without13 requiring13 a13 more13 skilled13 person13 to13 be13 onsite13 full-shy‐time)13 13


1413

In13 a13 review13 of13 an13 in-shy‐service13 training13 for13 community13 health13 nurses13 project13 in13 Fiji13 nurses13 and13 their13 supervisors13 were13 interviewed13 (Fiji13 Ministry13 of13 Health13 2011)13 A13 large13 percentage13 of13 supervisors13 had13 not13 encouraged13 their13 supervisees13 to13 assess13 their13 own13 training13 needs13 promoted13 the13 in-shy‐service13 training13 opportunities13 to13 them13 discussed13 topics13 with13 them13 or13 offered13 them13 any13 train-shy‐ing13 The13 nurses13 and13 their13 supervisors13 agreed13 that13 the13 present13 supervision13 and13 coaching13 approach13 was13 not13 working13 well13 for13 reasons13 including13 lack13 of13 transportation13 for13 visits13 lack13 of13 radio13 telephones13 for13 communication13 and13 lack13 of13 training13 in13 supervision13 and13 coaching13 for13 the13 supervisors13 However13 nurses13 believed13 that13 their13 supervisors13 had13 the13 necessary13 professional13 knowledge13 While13 the13 survey13 results13 indicated13 an13 average13 of13 three13 to13 four13 visits13 by13 supervisors13 during13 201013 the13 visits13 were13 not13 necessarily13 focused13 on13 supervision13 and13 coaching13 and13 nurses13 close13 to13 supervisors13 had13 four13 visits13 while13 some13 remote13 nurses13 had13 none13 13

Finally13 the13 report13 concluded13 that13 both13 nurses13 and13 supervisors13 needed13 a13 better13 understanding13 of13 their13 roles13 in13 the13 supervision13 and13 coaching13 process13 specifically13 for13 supervisors13 to13 learn13 how13 to13 create13 an13 atmosphere13 of13 trust13 to13 be13 able13 to13 talk13 openly13 without13 seeming13 overly13 critical13 and13 for13 nurses13 to13 understand13 that13 the13 aims13 of13 supervision13 and13 coaching13 are13 support13 and13 assessing13 and13 meeting13 training13 needs13 rather13 than13 performance13 review13 (Fiji13 Ministry13 of13 Health13 2011)13 13

The13 Global13 Health13 Workforce13 Alliance13 (2008)13 identified13 three13 elements13 essential13 to13 the13 effec-shy‐tiveness13 of13 community13 workers13 being13 paid13 having13 proper13 supervision13 and13 being13 embedded13 in13 the13 health13 system13 The13 authors13 suggested13 that13 mid-shy‐level13 workers13 supervise13 community13 work-shy‐ers13 and13 noted13 the13 Brazilian13 ratio13 in13 which13 one13 nurse13 supervises13 six13 community13 health13 workers13 but13 did13 not13 give13 details13 of13 successful13 models13 outside13 of13 formal13 training13 situations Joynes13 (2011)13 also13 recognised13 the13 importance13 of13 building13 the13 capability13 of13 community13 health13 workers13 sug-shy‐gesting13 distance13 learning13 mediated13 by13 technology13 as13 a13 solution13 13

A13 model13 for13 evaluating13 and13 then13 improving13 primary13 healthcare13 has13 proven13 effective13 in13 diabetes13 treatment13 in13 remote13 parts13 of13 Australia13 (Gardner13 et13 al13 2011)13 Three13 Fijian13 rural13 centres13 have13 been13 informally13 trialling13 it13 and13 Gardner13 et13 al13 (2011)13 suggest13 that13 it13 may13 prove13 effective13 in13 Pa-shy‐cific13 countries13 Keys13 to13 success13 for13 this13 continuous13 quality13 improvement13 model13 are13 similar13 to13 those13 for13 other13 change13 management13 approaches13 clear13 internal13 vision13 supportive13 leadership13 a13 stable13 team13 proven13 gains13 autonomy13 to13 make13 decisions13 and13 ongoing13 team13 discussions13

THE I NTERV I EW EES

The13 community13 health13 workers13 interviewed13 for13 this13 research13 demonstrate13 the13 diverse13 back-shy‐grounds13 and13 roles13 covered13 by13 the13 term13 It13 was13 not13 possible13 to13 classify13 them13 as13 paid13 or13 voluntary13 as13 several13 spanned13 both13 those13 categories13 echoing13 the13 comments13 about13 the13 import-shy‐ance13 of13 paying13 for13 this13 work13 if13 it13 is13 to13 be13 sustainable13 13

ldquoI13 am13 a13 Community13 Support13 Worker13 with13 the13 mental13 health13 service13 I13 have13 been13 working13 in13 the13 service13 for13 one13 year13 but13 I13 have13 been13 working13 as13 a13 volun-shy‐teer13 for13 about13 five13 years13 in13 the13 community13 I13 have13 been13 doing13 things13 like13 running13 around13 for13 different13 families13 when13 they13 want13 medicines13 transport13 assistance13 with13 English13 words13 and13 churchfamily13 mattersrdquo13 (Taiai13 Samoa)13

ldquoI13 work13 in13 the13 development13 field13 as13 a13 project13 officerrdquo13 (Mowenna13 Samoa)13

ldquoI13 work13 in13 a13 home13 for13 disabled13 and13 elderly13 people13 These13 people13 have13 no13 family13 to13 take13 care13 of13 them13 and13 the13 home13 is13 funded13 by13 the13 Catholic13 Churchrdquo13 (Naomi13 Tonga)13

13 ldquoI13 am13 a13 Community13 Health13 Worker13 Sometimes13 I13 do13 voluntary13 work13 for13 the13 village13 and13 the13 church13 But13 some13 of13 the13 time13 I13 am13 paidrdquo13 (Martha13 Papua13 New13 Guinea)13


1513

ldquo[My13 current13 role13 is]13 visiting13 community13 voluntarily13 as13 part13 of13 my13 pastor13 work13 I13 have13 lots13 of13 areas13 to13 cover13 I13 mainly13 connect13 people13 with13 the13 services13 they13 are13 wanting13 to13 connect13 with13 I13 mix13 in13 my13 pastor13 work13 with13 their13 enqui-shy‐ries13 I13 also13 work13 with13 other13 community13 health13 people13 in13 the13 community13 There13 are13 health13 doctors13 and13 community13 nurses13 I13 also13 talk13 to13 traditional13 healers13 where13 I13 meet13 up13 with13 them13 in13 the13 community13 These13 are13 very13 private13 people13 and13 are13 effective13 in13 helping13 our13 communities13 with13 their13 healthrdquo13 (Dona13 Fiji)13

ldquoI13 am13 currently13 a13 Volunteer13 Community13 Support13 Worker13 I13 work13 through13 the13 village13 very13 day13 and13 have13 no13 fixed13 hours13 People13 contact13 me13 through13 other13 people13 I13 generally13 work13 from13 my13 home13 baserdquo13 (Teni13 Vanuatu)13 13

The13 responses13 show13 the13 interplay13 of13 different13 roles13 and13 relationships13 in13 the13 communities13 in13 which13 they13 work13 13

ldquoPeople13 contact13 me13 through13 other13 peoplerdquo13 (Teni13 Vanuatu)13

ldquoI13 mainly13 connect13 people13 with13 the13 services13 they13 are13 wanting13 to13 connect13 with13 13 13 13 work13 with13 other13 community13 health13 people13 13 13 13 also13 talk13 to13 traditional13 healers13 where13 I13 meet13 up13 with13 them13 in13 the13 communityrdquo13 (Dona13 Fiji)13

ldquoI13 have13 been13 doing13 things13 like13 running13 around13 for13 different13 families13 when13 they13 want13 medicines13 transport13 assistance13 with13 English13 words13 and13 churchfamily13 mattersrdquo13 (Taiai13 Samoa)13

Other13 interviewees13 who13 gave13 their13 views13 on13 digital13 health13 for13 community13 health13 workers13 were13 a13 clinical13 co-shy‐ordinator13 (Tonga)13 a13 high13 school13 principal13 (Samoa)13 a13 doctor13 (Samoa)13 a13 nurse13 (Samoa)13 and13 an13 education13 manager13 (Tokelau)13 Their13 answers13 also13 provide13 insight13 into13 the13 role13 of13 community13 health13 workers13 in13 the13 Pacific13

ldquo13 13 13 we13 have13 a13 number13 of13 these13 health13 workers13 that13 work13 throughout13 the13 school13 as13 staff13 members13 and13 also13 as13 volunteers13 They13 are13 linked13 to13 us13 from13 the13 community13 initiatives13 in13 health13 and13 through13 the13 various13 government13 or-shy‐ganisations13 for13 the13 sake13 of13 the13 health13 and13 wellbeing13 of13 development13 of13 our13 studentsrdquo13 (High13 school13 principal13 Samoa)13

ldquoI13 work13 closely13 with13 a13 number13 of13 CSW13 [community13 support13 workers]13 who13 are13 people13 from13 this13 community13 Irsquom13 not13 sure13 if13 we13 call13 them13 CSW13 as13 they13 are13 not13 formally13 qualified13 like13 say13 the13 nurses13 or13 doctors13 but13 they13 are13 in13 the13 com-shy‐munity13 and13 make13 links13 between13 our13 work13 and13 the13 needs13 of13 the13 peoplerdquo13 (Doctor13 Samoa)13

ldquoMy13 thoughts13 are13 that13 CSW13 do13 a13 wonderful13 work13 in13 our13 communities13 Our13 communitiesrsquo13 needs13 would13 not13 be13 complete13 without13 their13 workrdquo13 (Clinical13 co-shy‐ordinator13 Tonga)13

ldquoI13 work13 alongside13 many13 CSW13 in13 my13 work13 both13 in13 the13 hospital13 and13 the13 com-shy‐munityrdquo13 (Nurse13 Samoa)13

The13 Tongan13 clinical13 co-shy‐ordinator13 described13 a13 Tongan13 model13 of13 supervision13 for13 community13 health13 workers13

ldquoWe13 also13 spend13 a13 lot13 of13 time13 doing13 one-shy‐to-shy‐one13 mentoring13 to13 assist13 the13 CSW13 in13 their13 work13 The13 issues13 that13 are13 challenging13 are13 time13 and13 expense13 Time13 in13 this13 context13 is13 about13 finding13 time13 in13 the13 very13 busy13 schedule13 that13 all13 com-shy‐munity13 people13 experience13 Travel13 into13 the13 villages13 is13 more13 than13 just13 travel13 Itrsquos13 the13 locating13 finding13 seeking13 out13 of13 significant13 contacts13 and13 family13 members13


1613

in13 order13 to13 engage13 in13 the13 interventions13 This13 is13 not13 a13 technology13 thing13 It13 is13 clearly13 a13 face-shy‐to-shy‐face13 relationship13 with13 the13 community13 that13 makes13 this13 work13 So13 clinically13 we13 have13 to13 make13 time13 and13 allow13 for13 this13 engagement13 and13 it13 can13 take13 hours13 days13 or13 weeksrdquo13

Technology infrastructure and access in the Pacific It13 is13 easy13 to13 think13 of13 ldquothe13 technology13 infrastructurerdquo13 as13 being13 all13 about13 ICT13 However13 Pacific13 countries13 also13 face13 challenges13 with13 other13 parts13 of13 their13 infrastructure13 especially13 on13 remote13 islands13 and13 in13 rural13 villages13 For13 example13 ordinary13 mail13 systems13 can13 be13 unreliable13 and13 uncertain13 for13 remote13 islands13 in13 the13 Pacific13 (Hughes13 et13 al13 2005)13 Similarly13 when13 describing13 Vanuatu13 media13 outlets13 Herman13 (2010)13 says13 ldquoNewsprint13 is13 expensive13 heavy13 to13 transport13 and13 susceptible13 to13 heat13 and13 humidity13 All13 these13 factors13 tend13 to13 mean13 that13 the13 Pacific13 print13 media13 is13 an13 urban13 medium13 13 13 13 Television13 viewers13 like13 newspaper13 readers13 are13 more13 likely13 to13 be13 town13 and13 city13 dwellers13 rather13 than13 rural13 villagers13 or13 re-shy‐mote13 islandersrdquo13

TECHNO LO GY STATI STI CS

Table13 213 presents13 statistics13 on13 the13 use13 of13 various13 technologies13 by13 country13 Fiji13 Australia13 and13 New13 Zealand13 are13 included13 for13 comparison13 the13 former13 being13 a13 leading13 Pacific13 country13 and13 the13 latter13 two13 being13 the13 more13 developed13 Commonwealth13 countries13 in13 the13 Pacific13 13

Table13 213 ICT13 use13 by13 country13

COUNTRY13

INTERNET13 USERS13 PER13 10013 13

INHABITANTS13

FIXED13 BROADBAND13 SUBSCRIPTIONS13

PER13 10013 INHABITANTS13

FIXED13 TELEPHONE13 LINES13 PER13 10013 INHABITANTS13

MOBILE13 CELLULAR13 SUBSCRIPTIONS13


13 200113 201013 200113 201013 200113 201013 200013 201013 Kiribati13 1813 9013 013 113 413 413 0413 1013

Nauru13 -shy‐13 6013 -shy‐13 413 1813 1813 1213 6013

PNG13 0813 1313 013 0113 113 213 0213 2813

Samoa13 0613 7013 013 0113 513 1913 113 9113

Solomon13 Islands13 0513 5013 013 0413 213 213 0313 613

Tonga13 2413 12013 013 113 1013 3013 0213 5213

Tuvalu13 5213 25013 013 313 713 1613 013 2513

Vanuatu13 2113 8013 013 0113 413 213 0213 11913

13

Australia13 46813 76013 0613 2313 5213 3913 4513 10113

New13 Zealand13 47413 83013 0113 2513 4713 4313 4013 11513

Fiji13 1513 14813 013 213 1113 1613 713 11613

Source13 International13 Telecommunications13 Union13 httpwwwituintITU-shy‐Dictstatisticsindexhtml13 downloaded13 1713 August13 201113

Note13 (-shy‐)13 indicates13 no13 data13


1713

Internet13 use13 is13 growing13 in13 all13 countries13 However13 the13 levels13 of13 Internet13 use13 in13 the13 eight13 Pacific13 countries13 that13 are13 the13 focus13 of13 this13 research13 as13 measured13 by13 number13 of13 Internet13 users13 and13 by13 fixed13 broadband13 subscriptions13 are13 low13 They13 are13 not13 yet13 close13 to13 the13 level13 that13 the13 more13 devel-shy‐oped13 Pacific13 countries13 demonstrated13 ten13 years13 ago13 Internet13 use13 in13 Tuvalu13 is13 increasing13 faster13 than13 in13 the13 other13 Pacific13 countries13 whereas13 Papua13 New13 Guinea13 has13 made13 very13 little13 progress13 in13 ten13 years13

Telephone13 use13 is13 also13 increasing13 In13 Australia13 and13 New13 Zealand13 the13 number13 of13 fixed13 telephone13 lines13 per13 10013 inhabitants13 is13 decreasing13 presumably13 as13 a13 result13 of13 the13 increasing13 use13 of13 mobile13 phones13 This13 is13 also13 happening13 in13 Vanuatu13 Fixed13 telephone13 line13 use13 has13 increased13 markedly13 in13 Samoa13 Tonga13 and13 Tuvalu13 and13 to13 a13 lesser13 extent13 in13 Fiji13 However13 in13 Kiribati13 Nauru13 Papua13 New13 Guinea13 and13 Solomon13 Islands13 fixed13 telephone13 use13 has13 changed13 very13 little13 in13 the13 last13 decade13 13

Mobile13 phone13 use13 has13 increased13 in13 every13 country13 over13 the13 same13 period13 In13 Samoa13 Vanuatu13 and13 Fiji13 201013 usage13 is13 comparable13 to13 Australian13 and13 New13 Zealand13 levels13 despite13 being13 markedly13 different13 in13 200013 Nauru13 and13 Tonga13 also13 have13 significant13 mobile13 phone13 use13 Over13 time13 if13 data13 on13 the13 extent13 of13 smartphone13 use13 become13 available13 they13 may13 expose13 differences13 between13 the13 less13 and13 more13 developed13 countries13 13

The13 rapid13 rise13 in13 mobile13 phone13 use13 can13 partly13 be13 attributed13 to13 a13 Digicel13 initiative13 launched13 in13 201013 (Devi13 2010)13 This13 initiative13 enables13 families13 in13 New13 Zealand13 to13 send13 remittances13 (the13 highest13 source13 of13 income13 in13 many13 Pacific13 countries)13 to13 relatives13 in13 Samoa13 Tonga13 Fiji13 Vanuatu13 Papua13 New13 Guinea13 and13 Nauru13 Digicel13 partnered13 with13 Ezi-shy‐pay13 to13 offer13 Top13 Up13 credit13 at13 thousands13 of13 dairies13 and13 convenience13 stores13 throughout13 New13 Zealand13 The13 New13 Zealand13 Pacific13 Island13 customers13 buy13 Digicel13 mobile13 Top13 Up13 vouchers13 (available13 in13 NZD13 1513 2013 3013 or13 5013 denominations)13 from13 their13 local13 prepaid13 outlet13 and13 then13 send13 the13 Top13 Up13 credit13 to13 any13 Digicel13 prepaid13 phone13 in13 the13 Pacific13 It13 automatically13 works13 out13 the13 amount13 in13 the13 local13 currency13 at13 no13 fee13

V ARI AB LE ACCESS TO TECHNO LO GY

A13 200713 survey13 of13 educational13 technologists13 by13 the13 Pacific13 eLearning13 Observatory13 at13 the13 Univer-shy‐sity13 of13 the13 South13 Pacific13 showed13 tertiary-shy‐level13 access13 to13 ICT13 across13 the13 region13 of13 7013 per13 cent13 but13 access13 between13 one13 and13 1113 per13 cent13 for13 primary13 and13 secondary13 students13 with13 overall13 access13 estimated13 to13 be13 1713 per13 cent13 (Whelan13 2008)13 The13 survey13 showed13 a13 digital13 divide13 between13 urban13 and13 rural13 Pacific13 populations13 Among13 the13 most13 commonly13 perceived13 challenges13 were13 lack13 of13 adequate13 financing13 lack13 of13 skilled13 personnel13 poor13 access13 to13 infrastructure13 and13 ICT13 equipment13 and13 low13 connectivity13 speeds13 13

A13 200913 study13 in13 Papua13 New13 Guinea13 showed13 that13 Internet13 use13 was13 primarily13 in13 urban13 centres13 mines13 and13 petroleum13 companies13 with13 only13 1513 per13 cent13 of13 the13 population13 having13 access13 to13 the13 Internet13 Unreliable13 electricity13 further13 limited13 Internet13 access13 for13 those13 who13 were13 theoretically13 connected13 While13 most13 of13 the13 health13 workers13 surveyed13 worked13 in13 hospitals13 only13 1413 per13 cent13 had13 access13 to13 the13 Internet13 at13 work13 Just13 under13 half13 of13 the13 workers13 had13 never13 used13 a13 computer13 and13 the13 majority13 who13 had13 had13 accessed13 it13 at13 home13 (Au13 2009)13

Lewis13 et13 al13 (2011)13 identified13 telecommunications13 infrastructure13 as13 one13 of13 four13 challenges13 to13 implementing13 ICT13 initiatives13 in13 the13 Pacific13 the13 other13 three13 being13 human13 capacity13 and13 training13 affordability13 and13 appropriateness13 The13 telecommunications13 infrastructure13 tends13 to13 be13 of13 lower13 quality13 as13 is13 observed13 in13 rural13 and13 remote13 communities13 in13 developing13 countries13 The13 authors13 found13 that13 overall13 ldquolimited13 and13 unequal13 access13 the13 high13 costs13 involved13 with13 both13 purchasing13 equipment13 and13 accessing13 its13 services13 insufficient13 bandwidth13 and13 an13 overall13 low13 investment13 in13 infrastructure13 networks13 make13 it13 extremely13 difficult13 to13 implement13 effective13 ICT13 projectsrdquo13


1813

The13 Solomon13 Islands13 People13 First13 Network13 (PFNet)13 began13 in13 200113 as13 an13 activity13 of13 the13 Rural13 Development13 Volunteers13 Association13 a13 partner13 agency13 of13 the13 Department13 of13 Provincial13 Gov-shy‐ernment13 and13 Constituency13 Development13 It13 was13 a13 community-shy‐based13 non-shy‐profit13 network13 of13 some13 3013 or13 more13 rural13 ldquoemail13 stationsrdquo13 run13 by13 the13 communities13 using13 shortwave13 (HF)13 radios13 with13 modems13 to13 exchange13 emails13 with13 the13 base13 station13 in13 Honiara13 and13 outward13 to13 the13 Internet13 Various13 information-shy‐sharing13 services13 operated13 over13 the13 network13 (Lemming13 2007)13 However13 in13 201113 the13 project13 appears13 to13 have13 stopped13 as13 the13 PFNet13 website13 is13 no13 longer13 operational13 An13 evaluation13 of13 the13 impact13 of13 PFNet13 on13 rural13 development13 noted13 that13 six13 per13 cent13 of13 those13 sur-shy‐veyed13 used13 PFNetrsquos13 services13 for13 health-shy‐related13 issues13 The13 main13 users13 were13 doctors13 nurses13 and13 health13 workers13 from13 different13 parts13 of13 Solomon13 Islands13 who13 used13 email13 to13 communicate13 with13 each13 other13 regarding13 medical13 results13 of13 rural13 patients13 diagnoses13 advice13 on13 treatment13 medi-shy‐cines13 to13 be13 given13 to13 patients13 and13 ordering13 of13 medicines13 (Chand13 Leeming13 Stork13 Agassi13 amp13 Biliki13 2005)13 13

A13 pilot13 tele-shy‐health13 project13 in13 Kiribati13 demonstrated13 that13 ensuring13 an13 affordable13 and13 sustainable13 technology13 infrastructure13 was13 a13 major13 challenge13 (Khazei13 Jarvis-shy‐Selinger13 Ho13 amp13 Lee13 2005)13 Pa-shy‐cific13 communities13 distributed13 across13 many13 small13 islands13 with13 small13 populations13 require13 innovative13 technological13 and13 business13 solutions13 specific13 to13 their13 contexts13 13

When13 interviewed13 community13 support13 workers13 identified13 limited13 access13 to13 technology13 includ-shy‐ing13 electricity13 as13 a13 major13 barrier13 to13 use13 of13 technology13 13

ldquoThe13 access13 issues13 are13 because13 the13 many13 areas13 where13 we13 work13 are13 remote13 areas13 and13 are13 also13 without13 electricity13 The13 people13 here13 are13 not13 bothered13 at13 all13 about13 the13 13 Internetrdquo13 (Nurse13 Samoa)13

ldquoThe13 only13 restriction13 is13 access13 Samoa13 has13 lots13 of13 interruptions13 in13 some13 places13 where13 I13 try13 to13 access13 onlinerdquo13 (Taiai13 Samoa)13

In13 some13 cases13 there13 is13 also13 the13 barrier13 of13 unequal13 access13 where13 the13 limited13 service13 available13 is13 used13 by13 the13 doctors13 and13 registrars13 As13 a13 result13 the13 community13 health13 workers13 and13 the13 com-shy‐munity13 do13 not13 experience13 the13 service13 and13 become13 aware13 of13 its13 potential13 benefits13 13

ldquoHowever13 it13 is13 very13 hard13 for13 a13 community13 health13 worker13 to13 have13 access13 to13 In-shy‐ternet13 or13 to13 have13 access13 to13 up13 to13 date13 online13 information13 as13 the13 online13 environment13 is13 not13 accessible13 We13 are13 far13 too13 isolated13 and13 it13 is13 very13 costly13 to13 be13 involved13 with13 this13 There13 is13 some13 difficulty13 with13 who13 owns13 the13 equipment13 and13 therefore13 access13 is13 restricted13 to13 special13 people13 like13 doctors13 and13 regis-shy‐trars13 I13 find13 this13 access13 not13 really13 relevant13 to13 my13 work13 Our13 villages13 are13 really13 isolated13 from13 connection13 with13 Internet13 and13 there13 is13 very13 little13 talk13 in13 the13 community13 about13 how13 this13 access13 might13 happen13 if13 at13 all13 Sometimes13 there13 is13 news13 on13 the13 radio13 about13 what13 the13 government13 is13 doing13 on13 Internet13 services13 but13 it13 seems13 to13 just13 go13 over13 their13 headsrdquo13 (Martha13 Papua13 New13 Guinea)13

Others13 understand13 the13 benefits13 but13 their13 jobs13 do13 not13 provide13 the13 necessary13 infrastructure13 so13 they13 do13 what13 they13 can13 to13 access13 the13 Web13 often13 through13 their13 relationships13

ldquoMy13 friend13 goes13 into13 the13 hospital13 and13 we13 sit13 together13 while13 she13 logs13 on13 as13 she13 has13 the13 password13 I13 then13 do13 what13 I13 need13 and13 then13 log13 off13 when13 I13 finish13 Some-shy‐times13 I13 take13 an13 hour13 sometimes13 I13 take13 1513 minutes13 depending13 what13 I13 need13 I13 have13 heard13 that13 other13 workers13 use13 the13 Internet13 cafeacutes13 in13 the13 town13 to13 do13 simi-shy‐lar13 work13 so13 I13 am13 lucky13 that13 I13 get13 to13 use13 the13 hospitalrsquos13 for13 freerdquo13 (Taiai13 Samoa)13

ldquoIf13 families13 do13 not13 have13 access13 to13 the13 Internet13 there13 are13 services13 available13 such13 as13 libraries13 Internet13 cafeacutes13 or13 family13 membersrdquo13 (Education13 manager13 Tokelau)13


1913

ldquoWhen13 I13 need13 to13 use13 the13 Internet13 I13 use13 the13 university13 online13 facilities13 I13 do13 this13 for13 my13 pastor13 work13 and13 so13 it13 is13 easy13 to13 attach13 my13 community13 work13 to13 this13 facility13 I13 use13 Google13 and13 other13 websites13 through13 the13 universityrdquo13 (Dona13 Fiji)13

POLHN13 is13 trialling13 innovative13 ways13 of13 overcoming13 limited13 access13 to13 the13 Internet13

ldquoIn13 places13 where13 there13 is13 difficult13 access13 to13 the13 Internet13 we13 have13 looked13 at13 the13 type13 of13 resource13 This13 is13 basically13 a13 hard13 drive13 that13 is13 loaded13 It13 requires13 a13 laptop13 or13 a13 computer13 to13 run13 but13 can13 get13 computers13 to13 remote13 locations13 just13 need13 [a]13 satellite13 for13 about13 USD13 8513 or13 a13 solar13 recharger13 to13 generate13 power13 for13 laptop13 battery13 It13 will13 take13 1213 hours13 overnight13 but13 it13 will13 do13 it13 A13 satellite13 had13 an13 interesting13 project13 in13 Africa13 that13 actually13 did13 work13 in13 getting13 remote13 access13 into13 remote13 areas13 they13 found13 that13 once13 they13 introduced13 the13 people13 in13 the13 village13 to13 technology13 they13 took13 advantage13 of13 it13 However13 I13 am13 fully13 con-shy‐vinced13 that13 we13 should13 not13 push13 technology13 where13 itrsquos13 not13 appropriaterdquo13 (Director13 POLHN)13

B U SI NESS MO DELS AND TECHNO LO GI STS

Along13 with13 telecommunications13 infrastructure13 Lewis13 et13 al13 (2011)13 identified13 human13 capacity13 and13 training13 affordability13 and13 appropriateness13 as13 challenges13 to13 implementing13 ICT13 initiatives13 in13 the13 Pacific13 13

Pacific13 countries13 have13 little13 human13 capacity13 in13 both13 the13 use13 of13 ICT13 and13 the13 set-shy‐up13 and13 mainte-shy‐nance13 of13 ICT13 and13 as13 a13 result13 must13 rely13 on13 expensive13 external13 contractors13 to13 fill13 the13 skill13 gap13 This13 can13 then13 lead13 to13 a13 second13 skill13 gap13 mdash13 poor13 understanding13 of13 the13 local13 context13 in13 which13 the13 ICT13 solutions13 are13 being13 implemented13 (Lewis13 et13 al13 2011)13 Higa13 (2007)13 suggests13 that13 the13 ICT13 skill13 gaps13 are13 across13 every13 level13 in13 the13 Pacific13 region13 in13 the13 public13 and13 private13 sectors13 ldquothose13 that13 design13 develop13 implement13 operate13 and13 manage13 networks13 and13 systems13 and13 those13 that13 are13 respon-shy‐sible13 for13 policy13 decisions13 and13 regulation13 of13 the13 ICT13 sectorrdquo She13 also notes13 the13 need13 to13 decrease13 reliance13 on13 expensive13 foreign13 ICT13 consultants

Lack13 of13 competition13 among13 ICT13 service13 providers13 whether13 state-shy‐13 or13 government-shy‐owned13 slows13 development13 and13 keeps13 prices13 high13 thus13 limiting13 uptake13 and13 use13 This13 also13 means13 that13 projects13 struggle13 to13 be13 sustainable13 once13 external13 funding13 ceases13 (Lewis13 et13 al13 2011)13 13

Most13 interviewees13 noted13 the13 cost13 of13 Internet13 access13 as13 a13 major13 barrier13 to13 use13 No13 other13 issue13 was13 mentioned13 as13 much13 This13 affected13 them13 in13 different13 ways13 including13 having13 no13 access13 having13 limited13 access13 choosing13 to13 limit13 access13 because13 of13 concern13 about13 perceptions13 of13 it13 being13 only13 for13 the13 rich13 and13 using13 alternative13 information13 sources13 instead13 Organisations13 try13 to13 work13 together13 to13 decrease13 costs13

ldquoOnline13 is13 expensive13 and13 people13 in13 roles13 like13 mine13 often13 work13 as13 volunteers13 so13 we13 need13 to13 have13 our13 own13 computer13 and13 online13 accessrdquo13 (Naomi13 Tonga)13

ldquoI13 know13 that13 the13 CSW13 have13 quite13 a13 good13 relationship13 with13 all13 our13 staff13 and13 students13 and13 that13 they13 access13 the13 Internet13 through13 the13 school13 system13 that13 is13 available13 in13 a13 very13 limited13 way13 through13 the13 school13 programmes13 and13 study13 programmes13 Each13 teacher13 is13 responsible13 for13 managing13 the13 Internet13 access13 and13 each13 one13 has13 control13 of13 managing13 the13 budget13 for13 the13 year13 It13 is13 very13 ex-shy‐pensive13 and13 I13 know13 that13 we13 could13 do13 with13 more13 updates13 in13 all13 our13 Internet13 functions13 13 13 13 We13 try13 not13 to13 discourage13 people13 who13 want13 to13 use13 it13 But13 as13 I13 said13 before13 it13 can13 be13 expensive13 and13 we13 have13 to13 limit13 this13 use13 13 13 13 A13 few13 years13 ago13 we13 didnrsquot13 even13 have13 computers13 so13 this13 is13 also13 a13 new13 learning13 curve13 for13 usrdquo13 (High13 school13 principal13 Samoa)13


2013

ldquoSometimes13 I13 am13 a13 bit13 shy13 to13 take13 my13 laptop13 into13 the13 villages13 as13 there13 is13 a[n]13 assumption13 that13 if13 you13 own13 one13 then13 you13 are13 rich13 or13 have13 many13 things13 This13 assumption13 can13 get13 in13 the13 way13 of13 the13 intervention13 or13 visit13 So13 we13 have13 to13 be13 humble13 with13 the13 CSW13 and13 play13 it13 down13 Most13 people13 know13 how13 expensive13 it13 is13 to13 have13 access13 Perhaps13 as13 a13 nurse13 I13 could13 leave13 the13 laptop13 behind13 when13 I13 go13 on13 visits13 so13 that13 I13 am13 not13 clutte[re]d13 by13 technology13 Money13 money13 money13 That13 is13 the13 key13 No13 money13 no13 accessrdquo13 (Nurse13 Samoa)13

ldquoExpense13 is13 a13 major13 consideration13 Each13 service13 and13 community13 has13 a13 defini-shy‐tion13 of13 what13 this13 might13 be13 and13 look13 like13 Where13 we13 can13 we13 have13 shared13 resources13 with13 allied13 services13 or13 like-shy‐mind[ed]13 service13 providers13 so13 that13 we13 can13 share13 what13 we13 both13 have13 For13 example13 in13 one13 of13 our13 units13 we13 share13 the13 printer13 and13 photocopier13 machines13 We13 also13 share13 the13 cost13 of13 the13 paper13 and13 maintenance13 of13 the13 machines13 Again13 traditional13 workers13 and13 village13 people13 do13 not13 necessar[il]y13 participate13 in13 this13 as13 they13 are13 distanced13 from13 the13 admin-shy‐istration13 side13 of13 the13 servicerdquo13 (Clinical13 coordinator13 Tonga)13

ldquoI13 go13 to13 the13 university13 library13 There13 is13 also13 some13 information13 that13 the13 church13 provides13 Sometimes13 I13 search13 the13 Internet13 but13 this13 is13 expensiverdquo13 (Naomi13 Tonga)13

ldquoOne13 of13 the13 challenges13 to13 rolling13 out13 and13 to13 making13 Internet13 access13 more13 available13 in13 the13 communities13 is13 the13 high13 cost13 It13 is13 still13 pretty13 high13 cost13 in13 most13 of13 the13 countries13 One13 of13 the13 things13 that13 SPC13 had13 [a]13 difficult13 time13 doing13 was13 their13 RIC13 [Remote13 Island13 Communication]13 system13 That13 provides13 the13 Internet13 access13 almost13 anywhere13 but13 the13 monthly13 cost13 is13 USD13 30013 for13 256k13 of13 service13 So13 what13 is13 happening13 is13 that13 although13 they13 had13 two13 years13 funding13 from13 AusAID13 and13 they13 have13 been13 pushing13 for13 community13 support13 and13 for13 sustain-shy‐ability13 and13 advocating13 for13 different13 segments13 of13 the13 community13 to13 come13 together13 not13 just13 education13 but13 health13 and13 others13 to13 support13 chip13 into13 that13 monthly13 recurring13 cost13 That13 has13 potential13 but13 itrsquos13 still13 in13 resource13 poor13 communities13 USD13 30013 a13 month13 is13 a13 lot13 of13 moneyrdquo13 (Director13 POLHN)13

The13 POLHN13 director13 also13 talked13 about13 the13 relatively13 new13 option13 in13 Fiji13 of13 using13 mobile13 phones13 to13 access13 the13 Internet13 but13 again13 cost13 of13 the13 phone13 and13 the13 access13 was13 a13 barrier13 to13 use13

ldquoIn13 Fiji13 the13 mobile13 phone13 companies13 we13 have13 managed13 to13 convince13 them13 and13 Irsquom13 not13 just13 saying13 [the13 World13 Health13 Organization]13 but13 a13 group13 of13 us13 from13 across13 different13 organisations13 and13 entities13 convinced13 the13 mobile13 phone13 providers13 to13 begin13 providing13 Web13 access13 as13 well13 as13 data13 from13 their13 mobile13 phone13 towers13 The13 challenge13 in13 the13 community13 is13 yes13 you13 can13 connect13 but13 can13 you13 pay13 for13 it13 The13 cost13 of13 data13 download13 can13 be13 fairly13 expensive13 plus13 it13 requires13 a13 higher13 end13 mobile13 phone13 than13 most13 people13 have13 Although13 I13 shouldnrsquot13 say13 it13 Irsquom13 always13 amazed13 that13 people13 that13 make13 very13 little13 money13 invest13 an13 awful13 lot13 in13 their13 mobile13 phone13 Most13 of13 the13 market13 will13 be13 going13 to13 the13 lower13 end13 phone13 rather13 than13 higher13 and13 that13 offers13 an13 opportunity13 as13 well13 The13 challenge13 is13 to13 work13 on13 training13 people13 on13 computer13 and13 including13 phone13 literacy13 and13 accessing13 the13 Web13 through13 phones13 other13 than13 just13 mak-shy‐ing13 phone13 callsrdquo13 (Director13 POLHN)13

The13 final13 challenge13 identified13 by13 Lewis13 et13 al13 is13 appropriateness13 of13 technology13 Software13 and13 support13 materials13 tend13 to13 be13 written13 in13 English13 Much13 of13 the13 electronic13 equipment13 wears13 out13 in13 the13 tropical13 climate13 and13 it13 is13 difficult13 to13 replace13 worn-shy‐out13 or13 superseded13 technology13 in13 remote13 isolated13 areas13 (Lewis13 et13 al13 2011)13


2113

Community health and ICT policies in the Pacific Policy13 affects13 community13 health13 workersrsquo13 digital13 health13 literacy13 in13 two13 ways13 mdash13 through13 the13 health13 system13 and13 the13 technology13 infrastructure13 (Diagram13 1)13 This13 section13 summarises13 regional13 and13 national13 policies13 relevant13 to13 ICT13 or13 community13 health13 in13 the13 Pacific13 countries13 covered13 in13 this13 study13

REGI O NAL DI GI TAL HEALTH I NI TI ATI V ES

Pacific13 countries13 are13 very13 aware13 of13 the13 potential13 of13 ICT13 in13 tackling13 health13 challenges13 they13 collec-shy‐tively13 face13 There13 is13 also13 a13 focus13 on13 working13 together13 to13 be13 most13 efficient13 and13 increase13 the13 chances13 of13 succeeding13

The13 Pacific13 has13 problems13 caused13 by13 large13 distances13 small13 scale13 and13 scattered13 populations13 and13 markets13 and13 a13 low13 level13 of13 investments13 in13 telecommunica-shy‐tions13 and13 human13 resources13 All13 these13 problems13 can13 be13 addressed13 and13 the13 development13 of13 ICTs13 accelerated13 by13 selection13 of13 appropriate13 mechanisms13 for13 cooperation13 market13 integration13 and13 provision13 of13 services13 on13 a13 regional13 basis13 (Pacific13 Islands13 Forum13 Secretariat13 2007)13 13

However13 it13 has13 proven13 difficult13 to13 successfully13 implement13 the13 promise13 of13 ICT13

Numerous13 studies13 have13 highlighted13 both13 the13 potential13 of13 and13 impediments13 to13 ldquoICTs13 for13 every13 Pacific13 Islanderrdquo13 The13 Communication13 Action13 Plan13 (CAP)13 and13 Pacific13 Islands13 Information13 and13 Communications13 Technologies13 Policy13 and13 Strategic13 Plan13 (PIIPP)13 have13 recently13 made13 clear13 recommendations13 on13 actions13 required13 for13 ICTs13 to13 reach13 potential13 in13 the13 region13 However13 countries13 have13 been13 less13 than13 successful13 in13 following13 these13 recommendations13 due13 to13 chal-shy‐lenges13 such13 as13 scale13 institutional13 capacity13 and13 isolation13 (Pacific13 Islands13 Forum13 Secretariat13 2007)13

Secretariat of the Pacific Communityrsquos Public Health Programme Strategic Plan

The13 Secretariat13 of13 the13 Pacific13 Community13 is13 a13 technical13 and13 development13 organisation13 that13 pro-shy‐vides13 advice13 and13 services13 to13 its13 2213 Pacific13 Island13 members13 It13 seeks13 to13 achieve13 sustainable13 economic13 development13 sustainable13 natural13 resource13 management13 and13 development13 and13 sus-shy‐tainable13 human13 and13 social13 development13 It13 aims13 to13 develop13 the13 technical13 professional13 scientific13 research13 planning13 and13 management13 capability13 of13 people13 and13 countries13 across13 the13 region13

The13 Secretariat13 of13 the13 Pacific13 Communityrsquos13 Public13 Health13 Programme13 Strategic13 Plan13 (2005)13 does13 not13 mention13 community-shy‐based13 initiatives13 However13 it13 does13 identify13 ldquomaintaining13 and13 further13 developing13 effective13 surveillance13 systems13 (PacNet)13 case13 detection13 (LabNet)13 and13 outbreak13 re-shy‐sponse13 (EpiNet)13 systemsrdquo13 as13 a13 ldquopivotal13 concernrdquo13

The13 sustainability13 of13 systems13 used13 to13 collate13 analyse13 and13 disseminate13 infor-shy‐mation13 and13 evidence13 for13 decision13 making13 is13 an13 important13 consideration13 Ensuring13 that13 the13 sources13 of13 new13 information13 and13 evidence13 are13 directly13


2213

linked13 with13 existing13 surveillance13 systems13 will13 increase13 the13 potential13 for13 effec-shy‐tive13 use13 of13 these13 data13 and13 their13 longer13 term13 sustainability13 in13 influencing13 public13 health13 interventions13 Further13 improvements13 in13 existing13 routine13 surveil-shy‐lance13 will13 also13 enhance13 information-shy‐based13 decision13 making13 13 13

The13 plan13 also13 recognises13 that13 staff13 will13 need13 new13 skills13 to13 be13 able13 to13 use13 the13 technology13 and13 the13 information13 they13 can13 access13 It13 therefore13 includes13 regional13 system13 and13 staff13 development13 with13 the13 aims13 of13 improving13 access13 to13 and13 quality13 of13 information13 particularly13 countriesrsquo13 statistics13 to13 inform13 decision-shy‐making13 13

Pacific Public Health Surveillance Network

The13 Pacific13 Public13 Health13 Surveillance13 Network13 is13 a13 voluntary13 network13 of13 countries13 and13 organisations13 dedicated13 to13 the13 promotion13 of13 public13 health13 surveillance13 and13 appropriate13 response13 to13 the13 health13 challenges13 of13 2213 Pacific13 Island13 countries13 and13 territories13 Communicable13 diseases13 especially13 the13 out-shy‐break13 diseases13 are13 its13 top13 priority13 at13 present13 (Pacific13 Public13 Health13 Surveillance13 Network13 2011)13

One13 of13 the13 Pacific13 Public13 Health13 Surveillance13 Networkrsquos13 five13 strategies13 is13 ldquopromoting13 the13 use13 of13 e-shy‐mail13 and13 opening13 the13 network13 to13 new13 clients13 new13 services13 and13 other13 networksrdquo13 This13 strategy13 relies13 on13 the13 use13 of13 email13 through13 a13 moderated13 listserv13 called13 PacNet13 The13 focus13 of13 the13 listserv13 is13 ldquoto13 implement13 an13 early13 warning13 system13 by13 sharing13 timely13 information13 on13 outbreaks13 of13 disease13 so13 that13 others13 in13 the13 Pacific13 might13 take13 appropriate13 action13 when13 a13 threat13 has13 been13 identifiedrdquo13 The13 membership13 of13 this13 group13 includes13 ldquohealth13 professionals13 health13 related-shy‐scientists13 and13 health-shy‐related13 decision13 makers13 doctors13 medical13 officers13 nurses13 biologists13 medical13 statisticians13 labora-shy‐tory13 specialists13 epidemiologists13 paramedics13 public13 health13 decision13 makersrdquo13 mdash13 it13 seems13 to13 include13 every13 health13 professional13 except13 community13 health13 workers13 There13 is13 a13 second13 subgroup13 restricted13 to13 higher-shy‐level13 decision13 makers13 in13 each13 country13 to13 communicate13 non-shy‐verified13 outbreak13 messages13 to13 alert13 countries13 to13 possible13 risks13 as13 soon13 as13 possible13 13

The13 Network13 also13 supports13 PacNet-shy‐Lab13 a13 listserv13 for13 LabNet13 a13 network13 of13 laboratory13 providers13 for13 identifying13 and13 confirming13 disease13 outbreaks13 EpiNet13 is13 a13 network13 of13 national13 and13 regional13 teams13 to13 investigate13 and13 respond13 to13 outbreaks13 13

Pacific Digital Strategy

The13 Pacific13 Islands13 Forum13 is13 a13 political13 grouping13 of13 1613 countries13 including13 the13 eight13 countries13 that13 are13 covered13 in13 this13 study13 as13 well13 as13 Australia13 Fiji13 and13 New13 Zealand13 The13 Forum13 Secretariat13 is13 responsible13 for13 implementing13 the13 Pacific13 Plan13 for13 Strengthening13 Regional13 Cooperation13 and13 Integration13 The13 plan13 (Pacific13 Islands13 Forum13 Secretariat13 2007)13 states13 that13 ldquocountries13 in13 the13 re-shy‐gion13 have13 been13 unable13 to13 fully13 utilise13 this13 cost-shy‐effective13 mass13 ICT13 with13 its13 potential13 to13 provide13 high13 quality13 education13 health13 and13 other13 services13 as13 well13 as13 entertainmentrdquo13 It13 includes13 in13 its13 steps13 for13 immediate13 implementation13 a13 digital13 strategy13 that13 recognises13 the13 potential13 of13 an13 im-shy‐proved13 ICT13 infrastructure13 to13 support13 health13 services13 13

However13 while13 the13 Pacific13 Digital13 Strategy13 grapples13 with13 the13 challenges13 of13 establishing13 a13 reli-shy‐able13 ICT13 infrastructure13 in13 the13 Pacific13 it13 does13 not13 include13 in13 its13 scope13 how13 to13 then13 use13 ICT13 to13 enhance13 health13 services13

Several13 initiatives13 within13 the13 Pacific13 Digital13 Strategy13 were13 recognised13 as13 being13 able13 to13 support13 dissemination13 of13 health13 information13 in13 rural13 and13 remote13 Pacific13 communities13 These13 include13

bull Pacific13 Rural13 Internet13 Connectivity13 System13 mdash13 1313 Pacific13 Island13 nations13

bull Oceania13 One13 Laptop13 per13 Pacific13 Child13 initiative13 mdash13 2213 Pacific13 Island13 nations13 13

bull South13 Pacific13 Information13 Network13 mdash13 undersea13 fibre13 network13


2313

The13 Pacific13 Rural13 Internet13 Connectivity13 System13 is13 a13 satellite13 Internet13 service13 designed13 especially13 for13 rural13 and13 remote13 areas13 of13 the13 Pacific13 (see13 httpwwwpacricsnet)13 The13 project13 provides13 the13 infrastructure13 and13 fully13 funds13 ldquopublic13 good13 sitesrdquo13 In13 December13 200913 Kiribati13 had13 eight13 sites13 Papua13 New13 Guinea13 two13 and13 Samoa13 three13 Papua13 New13 Guinea13 had13 indicated13 interest13 in13 4013 other13 units13 Tonga13 ten13 and13 Vanuatu13 1513 to13 2013 AusAID13 support13 ceased13 at13 the13 end13 of13 200913 and13 in13 201013 the13 existing13 telecommunications13 provider13 and13 the13 Secretariat13 of13 the13 Pacific13 Community13 agreed13 on13 providing13 coverage13 for13 another13 year13

The13 One13 Laptop13 per13 Pacific13 Child13 initiative13 a13 joint13 project13 of13 the13 Secretariat13 of13 the13 Pacific13 Com-shy‐munity13 and13 the13 One13 Laptop13 per13 Child13 Foundation13 began13 in13 200713 The13 project13 focused13 on13 basic13 education13 (Hutak13 amp13 Thomson13 2010)13 A13 201013 external13 evaluation13 of13 the13 Solomon13 Islands13 pilot13 did13 not13 mention13 use13 of13 the13 technology13 for13 health13 (Australian13 Council13 for13 Educational13 Research13 2010)13 13

The13 report13 concluded13 that13 progress13 on13 the13 Pacific13 Rural13 Internet13 Connectivity13 System13 and13 Oce-shy‐ania13 One13 Laptop13 per13 Pacific13 Child13 initiative13 was13 encouraging13 but13 recognised13 the13 need13 to13 seek13 external13 funding13 to13 maintain13 the13 proposed13 roll-shy‐out13 of13 pilots13 (Secretariat13 of13 the13 Pacific13 Com-shy‐munity13 2008)13 While13 government13 delivery13 of13 health13 services13 was13 an13 objective13 in13 the13 first13 digital13 strategy13 it13 was13 not13 achieved13 ldquomost13 [Pacific13 Island13 countries]13 are13 struggling13 to13 meet13 basic13 needs13 in13 healthcare13 with13 the13 result13 that13 ICT13 in13 health13 is13 not13 a13 high13 priorityrdquo13 The13 report13 recommended13 as13 a13 regional13 activity13 within13 the13 next13 digital13 strategy13 that13 the13 region13 ldquo[d]evelop13 ICT13 components13 for13 all13 regional13 policy13 (eg13 energy13 education13 health13 the13 environment13 etc)rdquo13

Pacific Open Learning Health Net

Established13 in13 200313 by13 the13 World13 Health13 Organization13 the13 Pacific13 Open13 Learning13 Health13 Net13 (POLHN)13 aims13 to13 improve13 the13 quality13 of13 healthcare13 in13 the13 Pacific13 To13 achieve13 this13 it13 offers13 online13 information13 and13 self-shy‐paced13 and13 instructor-shy‐led13 courses13 13

POLHN13 provides13 open13 learning13 centres13 with13 the13 necessary13 technology13 and13 trained13 staff13 to13 en-shy‐able13 health13 professionals13 to13 access13 the13 Internet13 near13 where13 they13 live13 or13 work13 In13 201013 POLHN13 had13 2513 open13 learning13 centres13 established13 in13 1213 countries13 including13 Fiji13 Kiribati13 Nauru13 Samoa13 Solomon13 Islands13 Tonga13 Tuvalu13 and13 Vanuatu13 To13 date13 POLHN13 has13 delivered13 4013 courses13 to13 over13 100013 participants13 in13 the13 Pacific13

POLHN13 with13 its13 partners13 offers13 qualifications13 in13 medical13 laboratory13 technology13 public13 health13 health13 services13 management13 nursing13 and13 radiology13 Self-shy‐paced13 courses13 which13 POLHN13 can13 separately13 assess13 to13 give13 credit13 cover13 patient13 safety13 computing13 skills13 risk13 management13 classi-shy‐fying13 diseases13 and13 treatment13 of13 Pacific-shy‐relevant13 diseases13 (eg13 diabetes13 mosquito-shy‐borne13 diseases13 AIDS13 tuberculosis13 and13 sexually13 transmitted13 infections)13 POLHN13 estimates13 that13 each13 course13 will13 take13 12ndash2613 hours13 of13 learning13 to13 complete13 These13 self-shy‐paced13 courses13 or13 parts13 of13 them13 could13 be13 relevant13 for13 community13 health13 workers13

The13 POLHN13 website13 provides13 links13 to13 formal13 tertiary13 providers13 of13 online13 health13 courses13 face-shy‐to-shy‐face13 short13 courses13 in13 the13 region13 and13 other13 organisations13 using13 self-shy‐paced13 eLearning13 to13 increase13 access13 to13 continuing13 professional13 development13 for13 health13 workers13 For13 example13 the13 American13 Global13 Health13 eLearning13 Center13 offers13 online13 self-shy‐paced13 courses13 at13 no13 charge13 Topics13 include13 family13 planning13 and13 reproductive13 health13 antenatal13 and13 newborn13 care13 child13 survival13 treating13 HIVAIDS13 and13 infectious13 diseases13 and13 health13 systems13 Health13 professionals13 including13 com-shy‐munity13 health13 workers13 can13 use13 the13 learning13 centres13 to13 access13 these13 courses13 13

POLHN13 works13 closely13 with13 ministries13 of13 health13 in13 Pacific13 countries13 Designated13 local13 POLHN13 co-shy‐ordinators13 conduct13 ongoing13 needs13 assessments13 in13 the13 region13 As13 a13 result13 of13 these13 assessments13 new13 courses13 are13 identified13 for13 development13 and13 current13 courses13 are13 updated13 The13 co-shy‐ordinators13 also13 disseminate13 information13 on13 POLHN13 and13 provide13 student13 support13


2413

In13 interviews13 conducted13 as13 part13 of13 a13 report13 to13 the13 World13 Health13 Organization13 in13 200513 (Hughes13 et13 al13 2005)13 it13 was13 noted13 that13 Fiji13 and13 the13 Solomon13 Islands13 the13 only13 two13 countries13 that13 com-shy‐mented13 on13 POLHN13 were13 experiencing13 problems13 with13 the13 learning13 centres13 In13 the13 Solomon13 Islands13 the13 challenge13 was13 staffing13 the13 centres13 with13 individuals13 who13 could13 solve13 technical13 prob-shy‐lems13 and13 train13 health13 professionals13 to13 use13 the13 technology13 A13 200613 World13 Health13 Organization13 report13 on13 eHealth13 (World13 Health13 Organization13 2006)13 credited13 POLHN13 with13 the13 high13 rate13 of13 ICT-shy‐based13 training13 for13 health13 professionals13 in13 the13 Western13 Pacific13 region13 13

In13 the13 future13 subject13 to13 raising13 sufficient13 funding13 POLHN13 hopes13 to13

bull improve13 student13 support13 services13 at13 the13 country13 level13 by13 hiring13 and13 training13 more13 POLHN13 co-shy‐ordinators13

bull increase13 the13 number13 of13 courses13 including13 developing13 pilot13 courses13 in13 physical13 therapy13

bull providing13 a13 Pacific13 Islands13 package13 of13 health13 materials13 loaded13 on13 hard13 drives13 and13 distri-shy‐buted13 to13 health13 professionals13 particularly13 in13 rural13 and13 remote13 locations13

bull build13 capacity13 at13 medical13 schools13 through13 the13 development13 of13 an13 adjunct13 faculty13 system13 to13 increase13 the13 number13 of13 courses13 the13 institutions13 are13 able13 to13 deliver13 13

bull with13 their13 partners13 implement13 a13 regional13 continuing13 professional13 education13 programme13 13

bull increase13 bandwidth13 at13 the13 POLHN13 centres13 13

bull pilot13 mobile13 phone13 technology13 for13 telemedicine13 and13 continuing13 education13 based13 on13 mod-shy‐els13 used13 in13 other13 parts13 of13 the13 world13 13

bull pilot13 local13 development13 and13 delivery13 of13 courses13 in13 the13 Solomon13 Islands13 using13 the13 telecom-shy‐munications13 infrastructure13 developed13 by13 the13 Solomon13 Islands13 People13 First13 Network13 (PFNet)13

NATI O NAL HEALTH PLANS

A13 World13 Bank13 review13 (Negin13 et13 al13 2011)13 estimated13 that13 most13 Pacific13 island13 countries13 spend13 around13 7013 per13 cent13 of13 their13 annual13 health13 budgets13 on13 ldquocurative13 care13 and13 treatment13 overseas13 leaving13 little13 for13 preventative13 carerdquo13 For13 example13 Fiji13 spent13 less13 than13 three13 per13 cent13 of13 its13 health13 budget13 on13 public13 health13 between13 198213 and13 200013 13

However13 of13 the13 eight13 countries13 that13 are13 the13 focus13 of13 this13 study13 all13 except13 Nauru13 recognise13 the13 importance13 of13 community13 health13 workers13 in13 their13 most13 recent13 national13 health13 plans13 While13 Nauru13 identified13 the13 potential13 of13 ICT13 to13 enhance13 their13 health13 system13 Samoa13 Tuvalu13 and13 Vanu-shy‐atu13 did13 not13 mention13 the13 potential13 of13 ICT13 to13 improve13 their13 health13 systems13 Kiribati13 Papua13 New13 Guinea13 Solomon13 Islands13 and13 Tonga13 identified13 the13 importance13 of13 community-shy‐based13 health13 and13 the13 potential13 of13 ICT13 but13 did13 not13 link13 the13 two13 Fiji13 which13 was13 also13 included13 in13 the13 review13 of13 national13 health13 plans13 falls13 in13 the13 second13 group13

Thus13 the13 nine13 countries13 can13 be13 grouped13 into13 three13 categories13


bull community13 workers13 but13 not13 ICT13 potential13 included13 in13 national13 health13 plans13 (Fiji13 Samoa13 Tuvalu13 and13 Vanuatu)13

bull community13 workers13 and13 ICT13 potential13 included13 in13 national13 health13 plans13 (Kiribati13 Papua13 New13 Guinea13 Solomon13 Islands13 and13 Tonga)13


2513

ICT potential but not community workers included in national health plans

Nauru13

Naurursquos13 National13 Sustainable13 Development13 Strategy13 2005ndash202513 identified13 health13 needs13 but13 did13 not13 include13 community-shy‐based13 initiatives13 as13 part13 of13 the13 solution13 to13 these13 needs13 It13 also13 recog-shy‐nised13 the13 need13 to13 upgrade13 ICT13 infrastructure13 but13 did13 not13 provide13 details13 as13 to13 how13 to13 do13 this13 or13 suggest13 how13 this13 might13 contribute13 to13 improved13 health13 (Republic13 of13 Nauru13 and13 Secretariat13 of13 the13 Pacific13 Community13 2007)13

Community health workers but not the potential of ICT included in national health plans

Fiji13 13

The13 Fiji13 Ministry13 of13 Healthrsquos13 (2007)13 Strategy13 recognises13 the13 role13 of13 community13 health13 workers13 ldquoBasic13 health13 care13 is13 provided13 to13 all13 residents13 through13 a13 hierarchy13 of13 village13 health13 workers13 nursing13 stations13 health13 centres13 sub13 divisional13 hospitals13 and13 divisional13 and13 specialized13 hospi-shy‐talsrdquo13 However13 the13 strategy13 does13 not13 outline13 actions13 in13 which13 these13 workers13 will13 be13 involved13 Also13 there13 is13 no13 mention13 of13 technology13 use13 even13 though13 the13 first13 of13 six13 strategic13 goals13 is13 to13 ldquoMaintain13 an13 adequate13 Primary13 and13 Preventive13 Health13 Care13 Services13 and13 Promotion13 of13 Healthrdquo13

Samoa13

The13 Samoan13 health13 sector13 plan13 (Samoa13 Ministry13 of13 Health13 2007)13 acknowledges13 the13 importance13 of13 collaboration13 between13 ldquogovernment13 agencies13 traditional13 healers13 community13 based13 and13 non-shy‐government13 organisations13 to13 promote13 health13 and13 healthy13 life13 stylesrdquo13 Under13 service13 pro-shy‐viders13 the13 plan13 identifies13 two13 traditional13 health13 worker13 roles13 (traditional13 healers13 and13 traditional13 birth13 attendants)13 and13 community-shy‐based13 social13 structures13 (pule13 nuu13 fanau13 lalovaoa13 and13 tu-shy‐pulaga13 talavou13 mdash13 village13 mayors13 womenrsquos13 committees13 and13 youth13 and13 children)13 The13 plan13 does13 not13 mention13 technology13

Tuvalu13

The13 Tuvalu13 health13 strategy13 does13 not13 mention13 technology13 It13 recognises13 the13 potential13 for13 com-shy‐munity13 members13 to13 make13 public13 health13 projects13 more13 efficient13 but13 does13 not13 include13 a13 specific13 action13 (Tuvalu13 Ministry13 of13 Health13 2009)13

Vanuatu13

The13 Vanuatu13 Ministry13 of13 Health13 developed13 a13 health13 services13 plan13 through13 extensive13 consulta-shy‐tion13 (Vanuatu13 Ministry13 of13 Health13 2004)13 The13 plan13 stresses13 the13 important13 contribution13 of13 ldquoaid13 postsrdquo13 within13 the13 countryrsquos13 health13 system13 There13 are13 about13 18013 aid13 posts13 in13 Vanuatu13 15ndash4113 per13 province13 with13 an13 aid13 post13 in13 most13 villages13 The13 posts13 provide13 first13 aid13 and13 community13 educa-shy‐tion13 Communities13 local13 or13 provincial13 governments13 or13 church13 groups13 establish13 and13 fund13 the13 posts13 The13 Ministry13 of13 Health13 provides13 basic13 medicines13 and13 up13 to13 three13 months13 of13 training13 for13 village13 health13 volunteers13 who13 staff13 the13 aid13 posts13 The13 other13 three13 types13 of13 health13 facility13 in13 Vanuatu13 are13 hospital13 health13 centre13 and13 dispensary13 The13 ministry13 is13 responsible13 for13 these13 13

The13 plan13 has13 an13 ldquooverarching13 priorityrdquo13 of13 giving13 greater13 emphasis13 to13 primary13 health13 and13 com-shy‐munity-shy‐based13 public13 health13 services13 to13 increase13 immunisation13 rates13 and13 decrease13 the13 incidence13 of13 malaria13 tuberculosis13 diarrhoea13 and13 malnutrition13 It13 specifically13 mentions13 the13 aid13 posts13 and13 their13 ongoing13 role13 in13 education13 community13 development13 and13 basic13 first13 aid13 Community13 in-shy‐volvement13 is13 key13 to13 the13 planrsquos13 success13


2613

The13 essence13 of13 the13 Primary13 Health13 Care13 approach13 is13 to13 engage13 the13 staff13 and13 the13 community13 in13 improving13 the13 health13 status13 through13 cooperative13 efforts13 There13 was13 much13 evidence13 during13 the13 consultation13 process13 that13 strong13 rela-shy‐tionships13 exist13 and13 that13 the13 community13 leaders13 present13 at13 the13 workshops13 wished13 to13 take13 on13 new13 roles13 and13 to13 be13 engaged13 in13 the13 process13 of13 change13 How13 the13 Ministry13 taps13 into13 this13 energy13 will13 be13 the13 key13 to13 the13 success13 of13 this13 Plan13

The13 eighth13 of13 1413 recommendations13 was13 to13 ldquogive13 a13 higher13 priority13 to13 improving13 transportation13 and13 communication13 links13 in13 order13 to13 improve13 access13 for13 patients13 and13 to13 reduce13 the13 isolation13 of13 health13 workersrdquo13 including13 ldquoprogressively13 expand13 communication13 system13 to13 Level13 ImdashAid13 Postsrdquo13 However13 there13 was13 no13 mention13 of13 the13 potential13 of13 ICT13 to13 support13 this13 communication13

Both community workers and the potential of ICT included in national health plans

Kiribati13

One13 of13 six13 strategic13 objectives13 within13 the13 Kiribati13 health13 plan13 aims13 to13 improve13 public13 health13 ser-shy‐vice13 delivery13 (Kiribati13 Ministry13 of13 Health13 and13 Medical13 Services13 2008)13 A13 priority13 action13 within13 this13 objective13 is13 to13 strengthen13 district13 health13 facilitiesrsquo13 infrastructure13 and13 management13 through13 use13 of13 ICT13 A13 key13 driver13 for13 considering13 technology13 is13 increased13 effectiveness13 and13 efficiency13 However13 the13 plan13 does13 not13 specify13 how13 technology13 will13 help13 achieve13 these13 13

The13 plan13 recognises13 the13 role13 of13 community13 workers13 in13 seeking13 to13 improve13 Kiribatirsquos13 health13 sta-shy‐tus13 in13 specific13 areas13 and13 includes13 educating13 healthcare13 workers13 as13 a13 priority13 action13

Papua13 New13 Guinea13

Papua13 New13 Guinearsquos13 health13 plan13 (Government13 of13 Papua13 New13 Guinea13 2010)13 has13 a13 strong13 focus13 on13 developing13 the13 community13 health13 worker13 role13 and13 recognises13 the13 potential13 of13 ICT13 to13 im-shy‐prove13 communication13 with13 health13 workers13 However13 technology-shy‐relevant13 actions13 focus13 on13 infrastructure13 in13 hospitals13 13

Specifically13 the13 health13 plan13 for13 the13 next13 decade13 recognises13 the13 importance13 of13 all13 health13 profes-shy‐sionals13 in13 achieving13 the13 goals13 of13 the13 plan13 including13 community13 health13 workers13 There13 is13 a13 shortage13 of13 community13 health13 workers13 ldquowith13 low13 wages13 and13 insufficient13 capacity13 within13 train-shy‐ing13 facilities13 to13 produce13 the13 number13 of13 health13 workers13 neededrdquo13 13

The13 plan13 aims13 to13 progressively13 introduce13 community13 health13 posts13 a13 relatively13 recent13 initiative13 in13 place13 in13 a13 few13 areas13 and13 to13 strengthen13 community13 health13 postsrsquo13 links13 to13 communities13 Re-shy‐lated13 actions13 are13 to13 increase13 the13 number13 of13 community13 health13 workers13 and13 strengthen13 the13 village13 health13 volunteers13 programme13 Each13 community13 health13 post13 is13 to13 have13 three13 staff13 with13 skills13 in13 ldquomaternal13 and13 child13 health13 midwifery13 health13 promotion13 and13 community13 awareness13 programsrdquo13 including13 a13 labour13 room13 In13 addition13

A13 new13 focus13 for13 these13 facilities13 will13 be13 improving13 the13 interface13 between13 the13 community13 and13 formal13 health13 services13 ensuring13 that13 the13 community13 knows13 how13 to13 access13 the13 appropriate13 level13 of13 care13 as13 well13 as13 equipping13 them13 with13 the13 necessary13 skills13 and13 knowledge13 to13 better13 take13 responsibility13 for13 their13 own13 healthy13 living13 This13 latter13 aspect13 will13 be13 enhanced13 by13 encouragement13 of13 the13 use13 of13 informal13 healthcare13 from13 the13 community13 and13 family13 level13 including13 for13 example13 Village13 Health13 Volunteers13 13

13

13


2713

In13 discussing13 technology13 Papua13 New13 Guinearsquos13 health13 plan13 recognises13 the13 strong13 health13 radio13 network13 linking13 130013 facilities13 and13 the13 underdeveloped13 health13 ICT13 infrastructure13 which13 has13 13

little13 or13 no13 ICT13 connectivity13 between13 provinces13 and13 Port13 Moresby13 within13 provinces13 or13 even13 within13 hospitals13 and13 provincial13 health13 offices13 This13 is13 in13 an13 environment13 of13 a13 very13 good13 though13 expensive13 telephone13 system13 and13 mobile13 telephone13 systems13 that13 already13 have13 wide13 coverage13 and13 are13 steadily13 increas-shy‐ing13 in13 coverage13 and13 reducing13 costs13 to13 the13 users13 13 13

Solomon13 Islands13

The13 Solomon13 Islands13 Health13 Strategy13 (Solomon13 Islands13 Ministry13 of13 Health13 2006)13 emphasises13 community13 involvement13 in13 health13 solutions13

The13 Solomon13 Islands13 faces13 some13 unique13 challenges13 in13 the13 effective13 delivery13 of13 health13 service13 It13 is13 recognised13 that13 utilisation13 of13 healthcare13 is13 on13 the13 in-shy‐crease13 but13 communities13 make13 decisions13 in13 a13 society13 that13 still13 utilises13 home13 care13 with13 traditional13 healers13 and13 western13 medicine13 Those13 factors13 affecting13 demand13 for13 health13 services13 are13 poorly13 understood13 but13 the13 power13 of13 the13 health13 worker13 to13 affect13 health13 outcomes13 is13 increasingly13 acknowledged13 (p13 15)13

The13 strategy13 mentions13 training13 for13 community13 health13 workers13 and13 recognises13 the13 need13 to13 use13 ICT13 to13 improve13 communication13 between13 the13 ministry13 and13 health13 providers13 however13 it13 also13 notes13 the13 challenge13 of13 changing13 staff13 attitudes13 to13 achieve13 the13 potential13 benefits13

However13 technical13 improvements13 are13 still13 compounded13 by13 a13 culture13 of13 in-shy‐formation13 hoarding13 within13 the13 organisation13 Staff13 have13 had13 limited13 exposure13 to13 understanding13 the13 importance13 of13 communication13 and13 there13 is13 a13 need13 to13 make13 better13 use13 of13 communication13 systems13 by13 all13 MoH13 staff13 especially13 in13 terms13 of13 the13 radio13 network13 (p13 27)13

Tonga13

The13 Tongan13 Ministry13 of13 Healthrsquos13 latest13 plan13 (Tonga13 Ministry13 of13 Health13 2008)13 notes13 the13 need13 to13 increase13 the13 capability13 of13 community13 health13 centres13 and13 includes13 the13 use13 of13 ICT13 to13 ldquofoster13 effi-shy‐cient13 and13 effective13 health13 care13 delivery13 communications13 timely13 and13 accurate13 information13 sharing13 security13 and13 innovationrdquo13

Learn and connect through ICT for health

PO TENTI AL O F I CT TO ENHANCE HEALTH

The13 200613 global13 eHealth13 report13 (World13 Health13 Organization13 2006)13 noted13 the13 growth13 in13 eHealth13 from13 200013 to13 200513 primarily13 in13 wealthier13 countries13 13

Every13 day13 across13 the13 world13 people13 make13 improvements13 in13 health13 as13 a13 direct13 benefit13 of13 information13 and13 communication13 technologies13 (ICT)13 eHealth13 innova-shy‐tions13 like13 electronic13 health13 records13 computer-shy‐assisted13 prescription13 systems13 and13 clinical13 databases13 are13 transforming13 health13 today13 and13 hold13 even13 greater13 promise13 for13 the13 future13 ICT13 support13 clinical13 care13 provide13 health13 information13 to13


2813

the13 general13 public13 and13 scientific13 information13 to13 professionals13 They13 provide13 a13 platform13 for13 publishing13 disseminating13 health13 alerts13 and13 supporting13 adminis-shy‐trative13 functions13 13

In13 200613 the13 main13 use13 of13 ICT13 in13 a13 health13 context13 was13 providing13 online13 health13 information13 The13 report13 suggested13 that13 member13 countries13 develop13 multilingual13 resources13 to13 avoid13 the13 duplica-shy‐tion13 of13 every13 country13 creating13 their13 own13 and13 encouraged13 the13 development13 of13 open13 resources13 and13 a13 move13 to13 use13 eLearning13 to13 build13 ICT13 skills13 in13 health13 workers13 The13 report13 also13 noted13 the13 challenges13 of13 ensuring13 the13 quality13 of13 such13 materials13 and13 having13 interoperable13 health13 informa-shy‐tion13 systems13

In13 201013 the13 United13 Nations13 recognised13 the13 potential13 for13 technology13 especially13 mobile13 phones13 to13 improve13 health13 in13 developing13 countries13 The13 report13 (United13 Nations13 2010b)13 recognised13 the13 potential13 for13 such13 technologies13 to13 empower13 community13 health13 workers13 13

Advances13 in13 technology13 provide13 an13 opportunity13 to13 accelerate13 poverty13 reduc-shy‐tion13 through13 pathways13 not13 available13 to13 countries13 that13 developed13 earlier13 Reducing13 the13 technology13 gap13 can13 accelerate13 leap-shy‐frogging13 to13 innovative13 and13 low-shy‐cost13 development13 solutions13 Such13 technology13 facilitates13 communication13 and13 information13 exchange13 Simple13 access13 to13 mobile13 telephones13 translates13 into13 reductions13 in13 mortality13 rates13 through13 provision13 of13 information13 about13 prevention13 and13 treatment13 and13 improvement13 of13 transport13 to13 vital13 interven-shy‐tions13 (such13 as13 emergency13 obstetric13 care)13 long-shy‐distance13 learning13 better13 chances13 of13 survival13 and13 adaptation13 by13 sharing13 information13 on13 the13 location13 of13 pastures13 and13 water13 using13 mobile13 telephony13 and13 empowerment13 of13 com-shy‐munity13 health13 workers13 and13 other13 health13 personnel13 13

Dzenowagis13 (2009)13 identified13 the13 potential13 for13 ICT13 to13 enhance13 health13 provision13 in13 all13 countries13 by13 helping13 for13 example13 control13 costs13 cover13 health13 workforce13 shortages13 meet13 growing13 con-shy‐sumer13 expectations13 and13 support13 changing13 models13 of13 healthcare13 delivery13 She13 also13 recognised13 that13 for13 developing13 countries13 further13 benefits13 are13 decreasing13 the13 isolation13 of13 health13 workers13 and13 supporting13 locally13 relevant13 research13 Factors13 affecting13 health13 workersrsquo13 ability13 to13 use13 ICT13 to13 enhance13 health13 outcomes13 are13 costs13 access13 Internet13 speed13 technical13 and13 digital13 literacy13 of13 users13 and13 cross-shy‐border13 collaboration13 13

Developed13 countries13 are13 investing13 significantly13 in13 ICT13 for13 health13 Their13 use13 of13 ICT13 is13 evolving13 as13 users13 learn13 more13 and13 technologies13 advance13 There13 are13 many13 theoretical13 and13 policy13 papers13 dis-shy‐cussing13 how13 technology13 enhances13 health13 services13 but13 there13 is13 no13 evidence13 based13 on13 actual13 projects13 that13 supports13 these13 proposed13 benefits13 (Lewis13 et13 al13 2011)13 13

Khazei13 et13 al13 (2005)13 have13 also13 identified13 possible13 negative13 effects13 of13 tele-shy‐health13 including13 diver-shy‐sion13 of13 finite13 resources13 into13 tele-shy‐health13 increased13 dependency13 on13 third13 parties13 rather13 than13 empowering13 local13 providers13 and13 loss13 of13 cultural13 appropriateness13 in13 delivery13 13

PO TENTI AL I N THE PACI FI C

Health13 outcomes13 vary13 for13 the13 eight13 Pacific13 countries13 that13 are13 the13 focus13 of13 this13 report13 In13 some13 countries13 infectious13 diseases13 continue13 to13 be13 the13 major13 health13 concern13 In13 others13 non-shy‐communicable13 diseases13 are13 increasingly13 the13 major13 health13 issue13 The13 countries13 also13 vary13 in13 ge-shy‐ography13 populations13 culture13 languages13 history13 economics13 politics13 and13 loyalty13 to13 different13 colonial13 powers13 Therefore13 it13 is13 not13 surprising13 that13 they13 also13 vary13 in13 their13 healthcare13 systems13 which13 are13 ldquoinherently13 socially-shy‐basedrdquo13 (Lewis13 et13 al13 2011)13 13

These13 factors13 then13 drive13 ICT13 in13 meeting13 the13 countriesrsquo13 health13 needs13 In13 discussing13 health13 infor-shy‐mation13 systems13 Lewis13 et13 al13 (2011)13 suggest13 that13 a13 larger13 country13 such13 as13 Papua13 New13 Guinea13


2913

requires13 a13 relatively13 complex13 heath13 information13 system13 in13 contrast13 to13 Tokelau13 which13 with13 00313 per13 cent13 of13 Papua13 New13 Guinearsquos13 population13 can13 operate13 its13 health13 system13 effectively13 with13 more13 simple13 tools13 Other13 countries13 are13 between13 these13 two13 extremes13 however13 ldquoat13 a13 certain13 point13 in13 size13 there13 is13 likely13 to13 be13 an13 almost13 quantitative13 step13 change13 in13 systems13 requirements13 for13 ICTrdquo13

Technologies13 can13 assist13 health13 workers13 in13 the13 Pacific13 in13 three13 ways13 by13 addressing13

bull physical13 isolation13 ldquocompounded13 by13 their13 populations13 being13 widely13 distributed13 on13 hundreds13 of13 small13 islands13 located13 in13 an13 immense13 expanse13 of13 oceanrdquo13 (Lewis13 et13 al13 2011)13

bull professional13 isolation13 and13

bull limitations13 to13 the13 processes13 of13 distance13 consulting13 and13 distance13 education13 such13 as13 ldquoinad-shy‐equate13 professional13 contacts13 and13 excessive13 communication13 costsrdquo13 (Pryor13 Baravilala13 amp13 Katoanga13 2000)13

Pryor13 et13 al13 (2000)13 also13 identified13 several13 factors13 that13 can13 encourage13 the13 use13 of13 technology13 to13 improve13 health13 in13 the13 Pacific13 including13

bull the13 use13 of13 two13 regional13 tele-shy‐health13 networks13 PacNet13 and13 Western13 Pacific13 HealthNet13

bull exploiting13 existing13 systems13 and13 patterns13 of13 consultation13 and13 referral13 that13 link13 practitioners13 to13 Australia13 New13 Zealand13 or13 the13 USA13 with13 the13 preference13 depending13 upon13 each13 Pacific13 nationrsquos13 historic13 connections13 to13 one13 of13 these13 three13 countries13 and13

bull increased13 awareness13 and13 interest13 in13 tele-shy‐health13 among13 regional13 and13 donor13 agencies13

In13 their13 definition13 of13 tele-shy‐health13 Pryor13 et13 al13 (2000)13 include13 the13 use13 of13 ICT13 to13 support13 health13 workers13 over13 distance13 While13 they13 focus13 on13 the13 role13 of13 specialist13 health13 workers13 each13 example13 could13 have13 relevance13 to13 a13 community13 health13 worker13

bull contacting13 a13 more13 knowledgeable13 health13 specialist13 on13 the13 telephone13 for13 an13 opinion13

bull communicating13 with13 a13 person13 on13 an13 outer13 island13 via13 high-shy‐frequency13 radio13 regarding13 a13 diffi-shy‐cult13 situation13

bull seeking13 advice13 from13 a13 public13 health13 professional13 through13 email13

bull performing13 a13 search13 of13 the13 medical13 literature13 through13 the13 Internet13 and13

bull taking13 part13 in13 a13 live13 audio-shy‐13 or13 videoconference13 as13 part13 of13 a13 professional13 development13 op-shy‐portunity13

With13 the13 rapid13 uptake13 of13 mobile13 phones13 more13 than13 10013 countries13 are13 now13 investigating13 the13 potential13 of13 mobile13 phones13 to13 improve13 health13 outcomes13 (United13 Nations13 2010a)13 13

In13 Ghana13 for13 instance13 nurse13 midwives13 use13 mobile13 phones13 to13 discuss13 com-shy‐plex13 cases13 with13 their13 colleagues13 and13 supervisors13 In13 India13 mDhil13 sends13 text13 messages13 giving13 information13 about13 various13 rarely13 discussed13 health13 topics13 and13 supporting13 prevention13 and13 patient13 self-shy‐management13 efforts13 Rwanda13 uses13 a13 system13 of13 rapid13 SMS13 alerts13 through13 which13 community13 health13 workers13 inform13 health13 centres13 about13 emergency13 obstetric13 and13 infant13 cases13 enabling13 the13 cen-shy‐tres13 to13 offer13 advice13 or13 call13 for13 an13 ambulance13 if13 needed13 13 13

Given13 the13 low13 levels13 of13 Internet13 use13 technology13 infrastructure13 challenges13 high13 uptake13 of13 mo-shy‐bile13 phones13 in13 Fiji13 Vanuatu13 and13 Samoa13 and13 the13 growth13 in13 mobile13 phone13 use13 across13 all13 Pacific13 countries13 such13 mobile13 solutions13 seem13 appropriate13 for13 the13 Pacific13


3013

DI STANCE LEARNI NG

Joynes13 (2011)13 recognised13 the13 importance13 of13 building13 the13 capability13 of13 community13 health13 work-shy‐ers13 This13 review13 of13 formally13 accredited13 English13 courses13 including13 those13 focused13 on13 community13 health13 workers13 concluded13 that13 ldquothere13 is13 a13 real13 need13 to13 develop13 and13 evaluate13 new13 and13 innova-shy‐tive13 ways13 of13 trainingrdquo13 especially13 to13 meet13 the13 demand13 for13 community13 health13 workers13 The13 report13 suggested13 distance13 learning13 on13 its13 own13 or13 as13 part13 of13 a13 blend13 as13 a13 possible13 solution13 and13 noted13 its13 growing13 popularity13 Perceived13 benefits13 are13

bull increased13 and13 easier13 access13 to13 training13

bull lower13 cost13 and13

bull potential13 to13 learn13 in13 the13 workplace13 resulting13 in13 greater13 retention13 more13 relevant13 learning13 better13 application13 of13 learning13 and13 provision13 of13 community13 healthcare13 maintained13 during13 the13 training13 period13

As13 a13 distance13 learning13 provider13 for13 the13 health13 sector13 in13 the13 Pacific13 POLHNrsquos13 main13 focus13 for13 dis-shy‐tance13 learning13 courses13 is13 on13 higher-shy‐level13 health13 professionals13 such13 as13 doctors13 nurses13 and13 laboratory13 technicians13 However13 POLHN13 offers13 six-shy‐week13 online13 courses13 to13 community13 health13 workers13

ldquoIt13 is13 one13 of13 the13 reasons13 we13 set13 up13 POLHN13 Primarily13 for13 health13 workers13 to13 make13 access13 more13 available13 because13 of13 the13 cost13 We13 have13 pretty13 good13 usage13 but13 one13 thing13 that13 you13 and13 we13 need13 to13 put13 more13 thinking13 into13 is13 more13 train-shy‐ing13 and13 working13 with13 students13 When13 I13 do13 computer13 literacy13 training13 itrsquos13 not13 just13 the13 standard13 word13 processing13 web13 access13 and13 that13 but13 asking13 the13 stu-shy‐dents13 what13 type13 of13 access13 that13 they13 need13 and13 showing13 them13 how13 to13 access13 that13 online13 A13 problem13 based13 approach13 or13 a13 project13 based13 approach13 where13 it13 looks13 at13 what13 are13 the13 needs13 of13 the13 community13 and13 then13 tailoring13 the13 training13 in13 helping13 them13 finding13 the13 help13 that13 they13 need13 Not13 to13 give13 you13 the13 wrong13 impression13 but13 we13 always13 work13 with13 health13 workers13 that13 I13 do13 training13 for13 The13 range13 of13 these13 [is]13 community13 health13 workersrsquo13 courses13 for13 mosquito13 borne13 diseases13 malaria13 cardiovascular13 HIVAIDS13 and13 tuberculosis13 These13 courses13 are13 taught13 online13 to13 community13 health13 workers13 who13 had13 previous13 medical13 training13 not13 at13 doctor13 level13 but13 were13 nurses13 or13 above13 Six13 weeks13 long13 online13 They13 had13 to13 come13 up13 with13 their13 own13 presentation13 to13 the13 community13 And13 we13 did13 an13 evaluation13 in13 the13 community13 as13 to13 how13 well13 they13 did13 This13 would13 show13 if13 their13 intervention13 was13 effective13 Most13 of13 our13 focus13 is13 on13 nurses13 doctors13 lab13 technicians13 health13 professionals13 so13 I13 donrsquot13 want13 to13 give13 you13 the13 wrong13 impressionrdquo13 (Director13 POLHN)13

To13 be13 effective13 distance13 learning13 has13 certain13 prerequisites13 Koloto13 Katoanga13 and13 Tatila13 (2006)13 interviewed13 New13 Zealand-shy‐based13 Pacific13 eLearners13 to13 identify13 critical13 success13 factors13 for13 and13 barriers13 to13 their13 learning13 Critical13 success13 factors13 were13

bull access13 to13 and13 knowing13 how13 to13 use13 computers13 and13 the13 Internet13 13

bull help13 from13 tutors13 and13 class13 members13 in13 an13 environment13 that13 is13 supportive13 of13 information13 technology13 (IT)13 use13 13

bull attending13 class13 and13 handing13 in13 assignments13 on13 time13 13

bull access13 to13 information13 learning13 centres13 and13 other13 resources13 13

bull motivation13 and13 self-shy‐confidence13 13

bull understanding13 eLearning13 and13 course13 content13 13

bull family13 support13 13


3113

bull funds13 for13 tuition13 fees13 13

bull individual13 learning13

bull time13 to13 work13 on13 the13 course13 online13 and13 13

bull good13 command13 of13 English13 13

Barriers13 identified13 were13 13

bull lack13 of13 understanding13 of13 technology13 and13 course13 content13 13

bull lack13 of13 self-shy‐confidence13 and13 motivation13 13

bull cost13 and13 finance13 13

bull lack13 of13 access13 to13 computers13 13

bull lack13 of13 time13 management13 skills13 13

bull personal13 reasons13 and13 family13 commitments13 13

bull lack13 of13 writing13 communication13 and13 English13 language13 skills13 and13

bull lack13 of13 physical13 interaction13 with13 and13 support13 from13 tutors13 13

Similarly13 a13 survey13 of13 distance13 learners13 at13 the13 University13 of13 the13 South13 Pacific13 identified13 a13 number13 of13 barriers13 to13 the13 use13 of13 ICT13 for13 distance13 learning13 (Whelan13 2008)13 Students13 felt13 isolated13 in13 on-shy‐line13 courses13 They13 lacked13 the13 necessary13 academic13 skills13 such13 as13 writing13 and13 reading13 struggled13 with13 English13 as13 the13 main13 language13 of13 instruction13 when13 it13 was13 their13 second13 or13 third13 language13 lacked13 ICT13 skills13 had13 low13 levels13 of13 learner13 motivation13 and13 engagement13 and13 lacked13 support13 from13 family13 friends13 or13 people13 in13 the13 workplace13 Other13 barriers13 were13 the13 cost13 of13 and13 access13 to13 ICT13 and13 technical13 problems13 while13 studying13

Suggestions13 for13 improving13 the13 success13 of13 distance13 learners13 were13 forming13 local13 national13 and13 regional13 networks13 to13 develop13 local13 content13 using13 online13 tools13 to13 support13 collaboration13 trans-shy‐lating13 the13 learning13 management13 systemrsquos13 interface13 into13 local13 languages13 and13 providing13 induction13 courses13 and13 mentoring13 facilitating13 and13 coaching13 support13 services13 (Whelan13 2008)13 13

Hogan13 (2009)13 studied13 the13 effectiveness13 of13 distance13 learning13 modes13 used13 by13 the13 University13 of13 the13 South13 Pacific13 Some13 students13 preferred13 correspondence13 courses13 and13 resisted13 online13 deliv-shy‐ery13 because13 they13

bull had13 poor13 typing13 skills13 especially13 older13 learners13 although13 a13 face-shy‐to-shy‐face13 coaching13 of13 just13 1513 minutes13 led13 to13 much13 greater13 online13 interaction13

bull felt13 discomfort13 in13 interacting13 with13 other13 cultures13 but13 growing13 comfort13 as13 they13 found13 that13 the13 online13 forums13 allowed13 them13 to13 consider13 their13 responses13

bull experienced13 technical13 problems13 such13 as13 difficulties13 logging13 on13 Internet13 speed13 (even13 at13 University13 of13 South13 Pacific13 campuses13 in13 some13 countries)13 Internet13 access13 outside13 urban13 areas13 and13 Internet13 costs13 for13 personal13 access13

bull preferred13 ldquoFiji13 Time13 which13 refers13 to13 a13 very13 slow13 way13 of13 doing13 things13 13 13 13 students13 said13 they13 preferred13 to13 take13 correspondence13 courses13 even13 when13 the13 subject13 was13 available13 in13 face-shy‐to-shy‐face13 or13 online13 mode13 13 13 13 Fiji13 Time13 effect13 is13 most13 evident13 in13 older13 students13 13 13 13 This13 cultural13 abhorrence13 toward13 deadlines13 preference13 to13 work13 alone13 and13 reluctance13 to13 participate13 in13 online13 discussions13 are13 challenges13 that13 must13 be13 addressed13 in13 order13 to13 provide13 quality13 online13 coursesrdquo13 and13

bull preferred13 to13 work13 alone13 (it13 was13 more13 common13 for13 Indian13 students13 to13 prefer13 to13 work13 alone13 and13 for13 indigenous13 learners13 to13 prefer13 to13 work13 in13 groups)13 13


3213

However13 online13 delivery13 offered13 significant13 advantages13 over13 correspondence13 in13 delivery13 time13 and13 the13 time13 it13 took13 to13 get13 feedback13 on13 assignments13 Remote13 correspondence13 students13 were13 not13 receiving13 their13 course13 materials13 until13 six13 weeks13 into13 the13 course13 and13 did13 not13 get13 feedback13 on13 assignments13 until13 the13 course13 was13 over13 Online13 delivery13 transformed13 these13 turnaround13 times13 (Hogan13 2009)13

Both13 online13 and13 correspondence13 course13 students13 varied13 in13 the13 level13 of13 contact13 they13 had13 with13 their13 tutors13 often13 because13 of13 budgetary13 constraints13 They13 had13 lower13 pass13 rates13 than13 campus-shy‐based13 students13 Students13 in13 Vanuatu13 Tonga13 and13 Solomon13 Islands13 said13 it13 was13 difficult13 to13 study13 at13 home13 with13 their13 extended13 families13 present13 (Hogan13 2009)13

A13 review13 of13 an13 in-shy‐service13 training13 for13 community13 health13 nurses13 project13 in13 Fiji13 (Fiji13 Ministry13 of13 Health13 2011)13 noted13 the13 following13 training13 priorities13 emergency13 obstetrics13 and13 midwifery13 acci-shy‐dents13 and13 emergencies13 mental13 health13 and13 outbreaks13 and13 infectious13 diseases13

Digital literacy of community health workers in the Pacific Au13 (2009)13 assessed13 Papua13 New13 Guinea13 health13 workersrsquo13 knowledge13 of13 skills13 in13 and13 attitudes13 towards13 ICT13 The13 health13 workers13 were13 primarily13 hospital13 workers13 with13 only13 1513 per13 cent13 being13 community13 health13 workers13 As13 might13 be13 expected13 workers13 who13 owned13 gadgets13 and13 had13 ex-shy‐perience13 with13 ICT13 had13 higher13 skills13 This13 tended13 to13 correlate13 with13 higher13 educational13 qualifications13 and13 being13 male13 and13 younger13 Nearly13 9013 per13 cent13 of13 workers13 had13 used13 cell13 phones13 while13 only13 2913 per13 cent13 were13 using13 landlines13 Two-shy‐thirds13 did13 not13 know13 how13 to13 send13 an13 email13 and13 a13 further13 six13 per13 cent13 did13 not13 know13 how13 to13 send13 an13 email13 with13 an13 attachment13 Only13 1713 per13 cent13 knew13 how13 to13 search13 Medline13 for13 health13 information13 Nearly13 10013 per13 cent13 of13 the13 health13 workers13 self-shy‐assessed13 that13 they13 needed13 further13 computer13 training13 with13 9013 per13 cent13 be-shy‐lieving13 there13 would13 be13 value13 in13 increasing13 their13 technology13 skills13 13

Community13 health13 workers13 in13 the13 study13 being13 reported13 on13 here13 believed13 they13 had13 a13 reasonable13 level13 of13 digital13 literacy13 However13 some13 saw13 the13 need13 for13 training13 to13 overcome13 this13 barrier13 for13 others13 They13 have13 developed13 their13 own13 skills13 through13 a13 computer13 course13 or13 online13 study13 of13 their13 own13

ldquoI13 have13 had13 training13 for13 computers13 through13 my13 pastor13 work13 so13 that13 is13 how13 I13 know13 what13 to13 dordquo13 (Dona13 Fiji)13

ldquoI13 believe13 that13 they13 should13 be13 more13 independent13 and13 seek13 training13 and13 en-shy‐gagement13 with13 technology13 but13 I13 am13 not13 sure13 how13 this13 can13 happen13 because13 it13 is13 so13 different13 in13 the13 villages13 compared13 to13 the13 hospitals13 13 13 13 I13 did13 my13 training13 by13 correspondence13 and13 I13 learnt13 quickly13 how13 to13 access13 online13 This13 is13 why13 I13 be-shy‐lieve13 that13 CSW13 need13 to13 be13 more13 savvy13 in13 this13 areardquo13 (Nurse13 Samoa)13

ldquoYes13 I13 often13 go13 online13 for13 emails13 Facebook13 and13 Google13 because13 I13 have13 a13 general13 interest13 in13 the13 online13 services13 offered13 in13 Samoa13 I13 sometimes13 need13 in-shy‐formation13 for13 my13 studies13 and13 I13 just13 surf13 when13 I13 canrdquo13 (Taiai13 Samoa)13

However13 based13 on13 his13 experience13 training13 community13 health13 workers13 and13 with13 those13 in13 the13 community13 the13 POLHN13 director13 indicated13 a13 lower13 level13 of13 digital13 literacy13 and13 the13 need13 for13 on-shy‐going13 training13

ldquoThere13 is13 a13 wide13 variety13 of13 resources13 available13 on13 the13 Web13 I13 just13 spent13 time13 in13 the13 Marshall13 Islands13 training13 community13 health13 workers13 in13 accessing13 resources13


3313

on13 the13 Web13 and13 then13 determining13 which13 resources13 are13 credible13 and13 which13 arenrsquot13 and13 going13 through13 that13 process13 13

So13 when13 you13 get13 down13 to13 the13 community13 level13 unless13 you13 have13 somebody13 who13 has13 been13 in13 the13 One13 Laptop13 per13 Child13 Programme13 and13 thatrsquos13 a13 primary13 school13 programme13 and13 has13 had13 experience13 in13 computer13 web-shy‐based13 pro-shy‐grammes13 and13 accessing13 information13 over13 the13 Web13 unless13 you13 have13 someone13 who13 has13 got13 some13 experience13 in13 that13 and13 I13 donrsquot13 see13 the13 bulk13 of13 young13 peo-shy‐ple13 having13 that13 experience13 there13 really13 needs13 to13 be13 a13 lot13 of13 computer13 literacy13 training13 not13 a13 one-shy‐off13 but13 needs13 to13 be13 incorporated13 with13 education13 in13 schools13 One-shy‐off13 only13 provides13 limited13 experience13 And13 people13 get13 caught13 out13 if13 they13 need13 to13 have13 continued13 when13 they13 run13 into13 trouble13 or13 access13 to13 someone13 who13 can13 help13 them13 out13 or13 some13 way13 to13 do13 that13 in13 the13 online13 envi-shy‐ronment13 Then13 they13 tend13 to13 get13 very13 frustratedrdquo13 (Director13 POLHN)13

Two13 other13 respondents13 suggested13 appropriate13 types13 of13 training13 mdash13 the13 need13 to13 tailor13 training13 to13 fit13 the13 local13 context13 and13 the13 potential13 to13 train13 while13 working13

ldquowho13 would13 be13 providing13 this13 [training]13 and13 manage13 it13 to13 ensure13 that13 it13 is13 tai-shy‐lored13 to13 the13 communityrdquo13 (Education13 manager13 Tokelau)13

ldquoWe13 can13 organise13 people13 to13 train13 and13 learn13 as13 they13 work13 13 13 13 a13 sort13 of13 working13 in13 progressrdquo13 (Clinical13 co-shy‐ordinator13 Tonga)13

Some13 respondentsrsquo13 answers13 to13 the13 prompt13 ldquoTell13 me13 what13 difference13 this13 made13 to13 the13 com-shy‐munity13 you13 serverdquo13 demonstrated13 digital13 literacy13 with13 evidence13 of13 application13 in13 their13 community13

ldquoIt13 helps13 me13 understand13 their13 needs13 in13 a13 more13 big13 picture13 way13 mdash13 by13 seeing13 what13 is13 happening13 in13 other13 places13 and13 countries13 It13 helps13 me13 see13 other13 ways13 to13 help13 and13 support13 peoplerdquo13 (Naomi13 Tonga)13

ldquoI13 am13 more13 informed13 for13 information13 sharing13 I13 can13 give13 them13 answers13 that13 are13 research13 proven13 etc13 etc13 and13 I13 can13 give13 them13 the13 latest13 information13 Irsquom13 not13 sure13 if13 the13 information13 is13 helpful13 in13 the13 community13 because13 it13 seems13 all13 in13 one13 lump13 sum13 answer13 For13 example13 when13 someone13 asks13 me13 for13 information13 say13 on13 diabetes13 and13 as13 a13 pastor13 I13 will13 pray13 first13 with13 them13 then13 they13 feel13 much13 better13 about13 their13 situation13 Then13 if13 they13 enquire13 more13 about13 medica-shy‐tion13 and13 I13 donrsquot13 know13 the13 answer13 I13 might13 have13 a13 look13 online13 and13 then13 let13 them13 know13 the13 answer13 The13 community13 are13 still13 very13 simple13 in13 their13 beliefsrdquo13 (Dona13 Fiji)13

ldquoIt13 allows13 me13 to13 get13 up-shy‐to-shy‐date13 information13 and13 practices13 used13 within13 the13 field13 while13 also13 following13 up13 on13 lessons13 learned13 from13 other13 entities13 things13 that13 are13 not13 readily13 available13 in13 paper13 form13 within13 the13 countryrdquo13 (Mowenna13 Samoa)13

When13 asked13 ldquoWhen13 you13 hear13 the13 words13 lsquodigital13 literacyrsquo13 what13 thoughts13 come13 into13 your13 mindrdquo13 the13 community13 support13 workers13 did13 not13 answer13 or13 gave13 replies13 that13 were13 limited13 to13 static13 content13 and13 the13 computer13 as13 the13 only13 tool13 13

ldquoComputer13 languagerdquo13 (Naomi13 Tonga)13

ldquoComputer13 ICTrdquo13 (Dona13 Fiji)13 13

ldquoReading13 and13 learning13 using13 books13 and13 other13 literature13 that13 is13 not13 in13 paper13 format13 but13 can13 be13 viewed13 using13 a13 computer13 or13 eBook13 readerrdquo13 (Mowenna13 Samoa)13


3413

Similarly13 when13 asked13 to13 ldquodesign13 a13 dream13 of13 best13 digital13 online13 information13 and13 technology13 supportrdquo13 the13 community13 health13 workers13 tended13 not13 to13 answer13 directly13 Other13 answers13 to13 questions13 indicate13 that13 their13 present13 use13 is13 focused13 on13 email13 accessing13 a13 few13 websites13 and13 Google13 searches13 Given13 the13 ongoing13 access13 challenges13 it13 is13 not13 surprising13 that13 respondents13 have13 not13 experienced13 the13 possibilities13 of13 non-shy‐stop13 access13 to13 the13 Web13 such13 as13 searching13 the13 Web13 daily13 for13 information13 reading13 RSS13 feeds13 and13 actively13 using13 online13 communities13 and13 social13 media13 to13 find13 and13 connect13 to13 trusted13 advisors13 and13 do13 not13 aspire13 to13 local13 content13 creation13 of13 multimedia13 so13 that13 Pacific13 cultures13 and13 languages13 are13 better13 represented13 in13 health13 on13 the13 In-shy‐ternet13

According13 to13 Nabobo-shy‐Baba13 (2007)13 one13 of13 the13 challenges13 facing13 Pacific13 countries13 is13 developing13 the13 necessary13 digital13 literacy13 without13 losing13 their13 own13 culture13

Communication13 and13 language13 changes13 have13 occurred13 because13 of13 rapid13 chan-shy‐ges13 in13 ICT13 There13 is13 increased13 global13 connectivity13 but13 the13 media13 are13 creating13 a13 ldquocartography13 of13 differencerdquo13 in13 the13 Pacific13 There13 are13 increasing13 disparities13 in13 education13 some13 have13 access13 to13 ICT13 while13 some13 do13 not13 The13 question13 to13 ask13 is13 How13 do13 we13 handle13 this13 ldquodigital13 dividerdquo13 A13 more13 pertinent13 question13 for13 us13 however13 is13 ldquoHow13 do13 we13 decrease13 the13 disparities13 in13 education13 in13 the13 Pacific13 that13 ICT13 will13 increasingly13 createrdquo13 Perhaps13 the13 most13 critical13 issue13 is13 what13 do13 we13 have13 to13 do13 to13 ensure13 that13 Pacific13 children13 excel13 in13 computer13 or13 ICT13 skills13 while13 not13 losing13 touch13 with13 the13 cultural13 knowledges13 of13 their13 own13 people13

HEALTH AND CU LTU RAL LI TERACY I N THE PACI FI C

Low13 health13 literacy13 cultural13 barriers13 and13 limited13 English13 proficiency13 have13 been13 coined13 the13 ldquotriple13 threatrdquo13 to13 effective13 health13 communication13 ldquoThe13 culturally13 bound13 beliefs13 values13 and13 preferences13 a13 person13 holds13 influence13 how13 a13 person13 interprets13 healthcare13 messages13 Knowing13 about13 a13 patientrsquos13 language13 and13 culture13 is13 key13 for13 knowing13 how13 health13 literate13 the13 person13 is13 in13 a13 given13 situationrdquo13 (Singleton13 amp13 Krause13 2009)13 13 They13 recommend13 that13 health13 workers13 consider13 all13 three13 aspects13 of13 effective13 health13 communication13 when13 communicating13 with13 patients13 through13 such13 actions13 as13 being13 culturally13 self-shy‐aware13 (including13 being13 aware13 of13 onersquos13 own13 health13 bias)13 developing13 appropriate13 patient13 forms13 and13 educational13 materials13 and13 working13 with13 trained13 medical13 interpreters13 and13 cultural13 brokers13

HEALTH LI TERACY

A13 brief13 analysis13 of13 the13 health13 literacy13 levels13 of13 New13 Zealand13 Australia13 Canada13 the13 United13 States13 and13 the13 United13 Kingdom13 concluded13 that13 over13 half13 of13 the13 adults13 in13 each13 of13 these13 countries13 lack13 the13 necessary13 health13 literacy13 (Workbase13 2011)13 New13 Zealand13 and13 Australia13 had13 the13 highest13 rates13 of13 adults13 with13 adequate13 health13 literacy13 at13 4413 per13 cent13 The13 figures13 also13 indicate13 strong13 differences13 between13 ethnic13 groups13 with13 health13 literacy13 levels13 for13 Māori13 in13 New13 Zealand13 being13 20ndash2513 per13 cent13 lower13 (and13 males13 lower13 than13 females)13 and13 for13 black13 and13 Hispanic13 adults13 in13 the13 United13 States13 being13 29ndash3713 per13 cent13 lower13 than13 those13 for13 white13 adults13 in13 both13 countries13 Ca-shy‐nadians13 for13 whom13 French13 is13 their13 first13 language13 were13 also13 more13 likely13 to13 have13 lower13 health13 literacy13 13

New13 Zealand13 Australia13 Canada13 the13 United13 States13 and13 the13 United13 Kingdom13 perform13 highly13 in13 the13 United13 Nations13 assessment13 of13 human13 development13 based13 on13 measures13 of13 health13 educa-shy‐tion13 and13 living13 standards13 (United13 Nations13 Development13 Program13 2009)13 These13 five13 countries13 range13 from13 second13 to13 21st13 on13 the13 list13 By13 contrast13 the13 eight13 countries13 that13 are13 the13 focus13 of13 this13 report13 range13 from13 99th13 to13 148th13 or13 are13 not13 included13 in13 the13 United13 Nations13 ranking13 It13 is13


3513

therefore13 reasonable13 to13 assume13 that13 the13 health13 literacy13 of13 the13 Pacific13 countries13 will13 be13 signifi-shy‐cantly13 lower13

The13 assumption13 of13 low13 health13 literacy13 was13 supported13 by13 comments13 from13 some13 respondents13 in13 this13 research13 Low13 health13 literacy13 in13 turn13 means13 that13 the13 community13 health13 workers13 are13 less13 likely13 to13 feel13 a13 need13 to13 increase13 their13 health13 literacy13

ldquoMost13 of13 the13 time13 the13 information13 that13 I13 need13 is13 answered13 for13 me13 by13 some13 of13 my13 friends13 in13 the13 mental13 health13 service13 because13 the13 questions13 that13 the13 com-shy‐munity13 ask13 me13 are13 easy13 to13 answer13 13 13 13 Not13 too13 many13 ask13 ones13 that13 need13 on-shy‐line13 servicerdquo13 (Taiai13 Samoa)13

ldquoWe13 are13 often13 just13 needing13 to13 be13 available13 to13 explain13 things13 about13 growing13 old13 rather13 than13 explaining13 any13 medical13 expertise13 informationrdquo13 (Doctor13 Samoa)13

However13 community13 health13 workers13 rely13 on13 trusted13 people13 in13 communities13 perceived13 to13 have13 higher13 health13 literacy13 as13 well13 as13 doing13 their13 own13 research13 13

ldquoThe13 community13 health13 workers13 normally13 get13 any13 health-shy‐related13 information13 that13 they13 require13 for13 their13 community13 health13 programme13 through13 their13 near-shy‐est13 health13 information13 office13 Other13 times13 we13 just13 ask13 in13 the13 community13 and13 get13 answers13 that13 way13 We13 have13 some13 traditional13 village13 people13 who13 can13 help13 us13 with13 traditional13 advice13 but13 most13 of13 the13 time13 the13 information13 we13 need13 is13 in13 the13 community13 One13 time13 I13 needed13 some13 clinical13 advice13 so13 I13 asked13 the13 local13 community13 doctor13 in13 the13 health13 information13 service13 and13 he13 just13 told13 me13 ver-shy‐bally13 Any13 information13 in13 the13 villages13 is13 done13 like13 this13 These13 are13 remote13 and13 isolated13 from13 the13 city13 The13 communities13 here13 have13 no13 need13 for13 online13 learn-shy‐ing13 at13 this13 moment13 We13 also13 have13 very13 knowledgeable13 influence[r]s13 in13 our13 families13 who13 are13 able13 to13 give13 the13 community13 what13 they13 needrdquo13 (Martha13 Papua13 New13 Guinea)13

ldquoI13 rely13 on13 the13 experience13 of13 my13 colleagues13 or13 I13 source13 the13 information13 myself13 using13 resources13 that13 are13 available13 to13 merdquo13 (Teni13 Vanuatu)13

ldquoI13 ask13 for13 guidance13 from13 supervisors13 or13 research13 on13 the13 Internet13 and13 through13 booksrdquo13 (Mowenna13 Samoa)13

ldquoThere13 is13 lots13 of13 times13 when13 I13 am13 not13 sure13 where13 to13 find13 the13 answers13 but13 I13 ask13 around13 the13 community13 and13 the13 health13 services13 I13 also13 ask13 people13 that13 are13 connected13 with13 me13 through13 church13 and13 the13 missionrdquo13 (Dona13 Fiji)13

ldquoShould13 the13 need13 arise13 to13 utilise13 online13 information13 I13 will13 however13 I13 would13 normally13 make13 contact13 with13 colleagues13 lsquoin13 the13 knowrsquo13 first13 to13 use13 their13 exper-shy‐tiserdquo13 (Teni13 Vanuatu)13

Teni13 (Vanuatu)13 mentioned13 using13 a13 mobile13 phone13 to13 contact13 someone13 Nobody13 talked13 of13 email-shy‐ing13 an13 expert13 or13 other13 ways13 of13 making13 contact13 with13 people13 over13 the13 Internet13 They13 rely13 on13 experts13 whom13 they13 know13 and13 who13 are13 nearby13 13

LANGU AGE AND CU LTU RE

Exacerbating13 these13 low13 health13 literacy13 levels13 is13 the13 dominance13 of13 English13 as13 the13 most13 common13 language13 of13 online13 resources13 and13 health13 publications13 Estimates13 are13 that13 8013 per13 cent13 of13 online13 resources13 are13 in13 English13 with13 only13 1013 per13 cent13 of13 the13 worldrsquos13 population13 speaking13 English13 (Kick-shy‐busch13 2011)13 Finau13 Dever13 Finau13 and13 Yano13 (2000)13 noted13 that13 even13 with13 the13 multilingual13 policy13


3613

of13 the13 Pacific13 Health13 Dialog13 journal13 which13 allows13 authors13 to13 write13 articles13 in13 any13 of13 the13 major13 Pacific13 languages13 every13 paper13 had13 been13 written13 in13 English13 over13 the13 five13 years13 of13 their13 study13 They13 describe13 English13 as13 ldquothe13 dominant13 monolingual13 medium13 for13 regional13 dialoguerdquo13 13

A13 study13 in13 Zambia13 (Underwood13 Serlemitsos13 amp13 Macwangi13 2007)13 assessed13 approximately13 200013 Zambian13 adultsrsquo13 ability13 to13 understand13 health13 information13 in13 English13 and13 major13 Zambian13 lan-shy‐guages13 Those13 who13 had13 not13 gone13 beyond13 primary13 school13 understood13 Zambian13 materials13 better13 Those13 who13 had13 studied13 at13 level13 813 or13 higher13 in13 schools13 scored13 equally13 well13 on13 English13 and13 Zam-shy‐bian13 materials13 However13 all13 adults13 understood13 the13 level13 413 materials13 better13 than13 the13 level13 813 materials13 The13 authors13 concluded13 that13 simpler13 health13 information13 and13 producing13 material13 in13 patientsrsquo13 first13 languages13 would13 increase13 health13 literacy13

The13 Pacific13 has13 over13 80013 languages13 and13 the13 number13 of13 native13 speakers13 is13 small13 for13 many13 of13 these13 languages13 Developing13 language-shy‐specific13 resources13 to13 support13 an13 even13 smaller13 number13 of13 community13 workers13 is13 not13 cost-shy‐effective13 However13 the13 risk13 of13 relying13 on13 English13 resources13 is13 that13 the13 essence13 of13 the13 message13 is13 lost13 in13 translation13 because13 of13 the13 different13 language13 and13 culture13 The13 health13 message13 may13 be13 difficult13 to13 understand13 for13 the13 community13 health13 worker13 or13 for13 the13 community13 with13 whom13 they13 then13 seek13 to13 communicate13 13

One13 community13 health13 worker13 noted13 language13 as13 a13 possible13 reason13 why13 those13 in13 the13 com-shy‐munity13 might13 not13 seek13 to13 access13 online13 information13

ldquoBut13 regards13 to13 the13 community13 I13 would13 be13 surprised13 if13 any13 of13 them13 wanted13 to13 use13 or13 get13 information13 from13 this13 service13 There13 are13 language13 issues13 and13 also13 lsquoneedrsquo13 issues13 that13 might13 restrict13 or13 hinder13 their13 wanting13 to13 askrdquo13 (Taiai13 Samoa)13

As13 well13 as13 speaking13 different13 languages13 non-shy‐Western13 cultures13 rely13 less13 on13 reading13 and13 writing13 Eighty13 per13 cent13 of13 the13 worldrsquos13 population13 lives13 in13 oral13 and13 visual13 cultures13 mdash13 cultures13 that13 learn13 through13 listening13 and13 watching13 not13 through13 reading13 or13 writing13 (Goody13 quoted13 in13 Kickbusch13 2011)13 By13 extension13 Kickbusch13 (2011)13 sees13 the13 oral13 and13 visual13 potential13 of13 new13 technologies13

The13 new13 information13 technologies13 might13 provide13 learning13 opportunities13 that13 are13 more13 visual13 and13 interactive13 than13 pamphlets13 and13 older13 more13 didactic13 forms13 of13 health13 instructions13 They13 can13 be13 used13 individually13 in13 groups13 and13 in13 the13 classroom13 Learning13 about13 health13 by13 surfing13 the13 net13 visiting13 chat13 rooms13 and13 talking13 to13 others13 thousands13 of13 miles13 away13 with13 the13 same13 problem13 is13 al-shy‐ready13 a13 reality13 for13 some13 Maybe13 in13 the13 future13 when13 you13 get13 a13 pill13 bottle13 you13 will13 not13 be13 handed13 an13 object13 with13 a13 little13 label13 that13 nobody13 can13 read13 let13 alone13 understand13 Maybe13 you13 will13 get13 a13 short13 video13 with13 your13 pills13 or13 a13 message13 sent13 to13 your13 hand-shy‐held13 portable13 device13 that13 will13 explain13 what13 the13 medication13 is13 for13 and13 how13 to13 take13 it13 properly13 (with13 an13 inbuilt13 reminder)13

Pacific13 countries13 need13 content13 developed13 by13 them13 for13 them13 Media13 trends13 increasingly13 support13 individuals13 creating13 and13 uploading13 individually13 generated13 content13 including13 multimedia13 re-shy‐sources13 13

Robbins13 (2006)13 gives13 examples13 of13 how13 Pacific13 people13 can13 develop13 culturally13 relevant13 educa-shy‐tional13 multimedia13 ldquodecentralised13 methods13 that13 enable13 students13 and13 teachers13 to13 customise13 educational13 multimedia13 themselves13 and13 dialogic13 methods13 that13 provide13 local13 context13 through13 conversation-shy‐like13 interfaces13 13 13 13 educational13 tools13 include13 a13 virtual13 peer13 wiki13 self-shy‐test13 digital13 scrapbook13 and13 three-shy‐tier13 file13 structurerdquo13

Harris13 (2007)13 reviewed13 a13 video13 production13 project13 in13 Fiji13 in13 which13 rural13 women13 produced13 video13 stories13 that13 were13 important13 to13 them13 and13 their13 communities13 Producing13 the13 videos13 meant13 that13 the13 women13


3713

visited13 each13 othersrsquo13 communities13 leading13 to13 greater13 dialog13 and13 understand-shy‐ing13 The13 visit13 created13 a13 greater13 transference13 of13 knowledge13 and13 cross-shy‐cultural13 understanding13 Producing13 within13 their13 local13 context13 also13 allowed13 the13 women13 to13 integrate13 the13 social13 and13 cultural13 values13 of13 their13 own13 society13 and13 develop13 their13 own13 production13 culture13 instead13 of13 using13 foreign13 production13 values13 13

The13 ability13 of13 rural13 Pacific13 women13 to13 produce13 videos13 when13 supported13 the13 knowledge13 sharing13 as13 a13 result13 of13 the13 production13 process13 and13 the13 development13 of13 a13 Fijian13 production13 culture13 could13 be13 relevant13 to13 health-shy‐related13 projects13 that13 rely13 on13 culturally13 relevant13 knowledge13 transfer13

Those13 interviewed13 for13 this13 study13 did13 not13 mention13 local13 content13 production13

A13 study13 of13 Asian13 patients13 in13 the13 United13 States13 found13 that13 doctor13 and13 patient13 perceptions13 of13 conversations13 about13 complementary13 and13 alternative13 medicines13 were13 different13 even13 with13 doc-shy‐tors13 who13 were13 of13 the13 same13 ethnicity13 as13 the13 patients13 (Nguyen13 amp13 Bowman13 2007)13 The13 authors13 concluded13 that13 training13 for13 health13 professionals13 needs13 to13 ldquofocus13 on13 effective13 communication13 skills13 in13 an13 increasingly13 multilingual13 and13 multicultural13 society13 in13 which13 patients13 frequently13 have13 limited13 English13 language13 literacy13 skills13 Examples13 are13 the13 need13 for13 education13 about13 cultural13 competency13 and13 effective13 use13 of13 medical13 interpretersrdquo13 In13 addition13 they13 believed13 that13 health13 professionals13 need13 to ldquoaddress13 issues13 of13 culture13 language13 and13 health13 literacy13 when13 they13 communicate13 with13 these13 patients13 so13 that13 appropriate13 questions13 are13 asked13 and13 accurate13 infor-shy‐mation13 is13 exchanged13 between13 patients13 and13 their13 providersrdquo13 13

While13 the13 Nguyen13 and13 Bowman13 (2007)13 study13 targeted13 doctors13 the13 findings13 are13 also13 relevant13 for13 community13 health13 workers13 In13 addition13 community13 health13 workers13 have13 a13 potential13 role13 in13 supporting13 more13 effective13 communication13 between13 health13 professionals13 and13 patients13 but13 need13 to13 be13 respected13 enough13 to13 do13 that13 13

ldquoI13 see13 the13 need13 for13 the13 CSW13 [community13 support13 worker]13 to13 have13 informa-shy‐tion13 online13 but13 I13 donrsquot13 see13 them13 needing13 to13 access13 this13 In13 fact13 I13 have13 never13 been13 asked13 about13 online13 information13 since13 I13 have13 been13 working13 here13 I13 think13 it13 is13 probably13 not13 that13 big13 a13 need13 and13 I13 wonder13 too13 if13 this13 is13 the13 case13 because13 I13 am13 here13 and13 the13 nurses13 too13 13 13 13 There13 is13 a13 strong13 belief13 in13 the13 medically13 trained13 doctor13 and13 nurse13 and13 there13 is13 also13 a13 lot13 of13 trust13 invested13 by13 the13 peo-shy‐ple13 in13 us13 and13 we13 are13 responsible13 for13 delivering13 the13 right13 service13 in13 their13 eyes13 From13 time13 to13 time13 monetary13 gifts13 are13 given13 to13 us13 over13 and13 above13 our13 rate13 be-shy‐cause13 of13 their13 appreciation13 of13 our13 service13 I13 remember13 one13 woman13 inviting13 me13 to13 their13 toanarsquoi13 [special13 meal]13 with13 their13 extended13 family13 just13 as13 a13 way13 to13 say13 thank13 yourdquo13 (Doctor13 Samoa)13

CO MMU NI TY-RELEV ANT SO LU TI O NS

Another13 challenge13 community13 health13 workers13 face13 in13 providing13 culturally13 appropriate13 health13 services13 is13 taking13 their13 training13 often13 done13 in13 another13 country13 and13 applying13 it13 to13 the13 culture13 of13 the13 community13 in13 which13 they13 are13 working13 The13 social13 problems13 they13 face13 in13 their13 own13 country13 tend13 to13 be13 different13 in13 degree13 and13 kind13 to13 those13 in13 their13 country13 of13 training13 Therefore13 the13 skills13 needed13 to13 address13 them13 are13 also13 different13 (Mills13 2002)13

When13 discussing13 ways13 to13 build13 the13 capacity13 of13 mental13 health13 workers13 in13 the13 Pacific13 Hughes13 et13 al13 (2005)13 noted13 the13 potential13 of13 the13 Internet13 and13 other13 electronic13 media13 to13 enhance13 network-shy‐ing13 between13 more13 and13 less13 experienced13 practitioners13 However13 they13 stressed13 the13 importance13 of13 recognising13 Pacific13 cultural13 factors13 in13 designing13 technology-shy‐supported13 approaches13

These13 provide13 an13 opportunity13 for13 training13 and13 ongoing13 supervision13 and13 are13 par-shy‐ticularly13 useful13 for13 overcoming13 the13 isolation13 of13 sole13 practitioners13 providing13


3813

support13 and13 guidance13 and13 for13 preventing13 skills13 depletion13 over13 time13 How-shy‐ever13 any13 involvement13 of13 such13 media13 needs13 to13 consider13 that13 those13 interviewed13 placed13 heavy13 emphasis13 on13 the13 oral13 culture13 in13 Pacific13 countries13 the13 preference13 for13 a13 face-shy‐to-shy‐face13 approach13 for13 training13 and13 the13 need13 for13 close13 engagement13 with13 other13 local13 countries13 Ongoing13 support13 and13 mentor-shy‐ing13 was13 recognised13 as13 important13 but13 the13 approaches13 adopted13 needed13 to13 be13 appropriate13 and13 reflect13 the13 above13 factors13 13

They13 proposed13 careful13 piloting13 of13 such13 approaches13 and13 involvement13 of13 community13 and13 church13 leaders13 to13 ensure13 buy-shy‐in13 and13 sustainability13 of13 programmes13 Similarly13 a13 review13 of13 a13 community-shy‐based13 obesity13 prevention13 programme13 in13 Tonga13 concluded13 that13 keys13 to13 success13 for13 community-shy‐based13 interventions13 were13 the13 community13 understanding13 and13 agreeing13 on13 the13 need13 for13 interventions13 engaging13 community13 leaders13 and13 influencers13 and13 culturally13 appro-shy‐priate13 implementation13 (Fotu13 Moodie13 Mavoa13 Pomana13 Schultz13 amp13 Swinburn13 2011)13 13

Three13 projects13 led13 by13 the13 National13 Telemedicine13 Centre13 in13 the13 Philippines13 sought13 to13 use13 ICT13 to13 improve13 health13 outcomes13 (Marcelo13 2009)13 Each13 began13 with13 community13 involvement13 The13 implementation13 had13 three13 phases13

bull The13 human13 experience13 Start13 from13 where13 the13 people13 are13

bull The13 technological13 opportunity13 Identify13 appropriate13 available13 accessible13 and13 culturally13 acceptable13 technologies13 and13

bull The13 sustenance13 factor13 Embed13 the13 technology13 into13 the13 local13 fabric13

In13 considering13 the13 lessons13 learned13 about13 ldquothe13 human13 experiencerdquo13 Marcelo13 noted13 the13 import-shy‐ance13 of13 introducing13 the13 technology13 to13 enhance13 existing13 relationships13 or13 to13 meet13 a13 felt13 need13

The13 Community13 Health13 Information13 Tracking13 System13 ldquowas13 developed13 in13 close13 consultation13 with13 village13 health13 workers13 to13 best13 identify13 their13 needsrdquo13 (Marcelo13 2009)13 The13 system13 made13 community-shy‐based13 health13 information13 available13 to13 public13 health13 agencies13 requiring13 com-shy‐munity-shy‐level13 information13 and13 to13 the13 community13 that13 generated13 the13 information13 Village13 health13 workers13 enter13 information13 once13 during13 patient13 consultations13 which13 they13 can13 then13 access13 Community13 leaders13 can13 also13 access13 the13 data13 and13 reports13 immediately13 to13 help13 them13 make13 better13 timely13 decisions13 13

One13 lesson13 learned13 from13 the13 Community13 Health13 Information13 Tracking13 System13 project13 about13 training13 was13 that13 a13 fun13 game-shy‐based13 method13 using13 the13 existing13 game13 Solitaire13 was13 more13 effective13 than13 a13 more13 structured13 training13 programme13 in13 teaching13 health13 workers13 how13 to13 use13 the13 keyboard13 and13 mouse13 because13 trainees13 were13 more13 relaxed13 and13 less13 fearful13 (Marcelo13 2009)13

The13 game13 orientation13 removes13 the13 fear13 that13 they13 have13 to13 perform13 well13 in13 a13 short13 period13 of13 time13 This13 is13 what13 is13 meant13 by13 starting13 from13 where13 the13 peo-shy‐ple13 are13 A13 recognition13 of13 the13 cultural13 aspects13 of13 community13 life13 is13 important13 in13 starting13 them13 off13 into13 a13 new13 direction13 such13 as13 computerisation13 and13 automation13 13 13

The13 second13 project13 E-shy‐Learning13 for13 Health13 used13 whatever13 technologies13 were13 available13 and13 ap-shy‐propriate13 to13 train13 village13 health13 workers13 by13 distance13 (Marcelo13 2009)13 Most13 communities13 have13 televisions13 and13 video13 players13 so13 the13 sessions13 begin13 with13 health13 workers13 watching13 a13 sevenndashto-shy‐ten-shy‐minute13 video13 developed13 by13 the13 National13 Telemedicine13 Centre13 using13 non-shy‐technical13 language13 as13 much13 as13 possible13 Experts13 in13 Manila13 then13 interact13 with13 one13 or13 more13 groups13 of13 health13 workers13 by13 videoconference13 Internet13 or13 mobile13 phones13 to13 answer13 questions13

The13 E-shy‐Learning13 for13 Health13 Project13 has13 shown13 that13 by13 using13 locally13 available13 technology13 and13 the13 best13 available13 bandwidth13 it13 is13 possible13 to13 establish13


3913

interaction13 between13 a13 group13 of13 healthcare13 volunteers13 (in13 a13 remote13 com-shy‐munity)13 and13 an13 expert13 (in13 an13 urban13 area)13 Voice13 calls13 were13 found13 to13 be13 most13 effective13 although13 participants13 also13 appreciated13 videoconferencing13 The13 community13 members13 were13 keen13 to13 accept13 the13 new13 modality13 be-shy‐cause13 it13 employed13 technologies13 that13 were13 already13 familiar13 to13 them13 Pre-shy‐tests13 and13 post-shy‐tests13 given13 to13 participants13 revealed13 that13 they13 were13 able13 to13 gain13 knowledge13 from13 the13 e-shy‐learning13 activity13

However13 a13 significant13 challenge13 in13 eHealth13 is13 developing13 sustainable13 models13 Marcelo13 (2009)13 asked13 the13 question13 and13 provided13 at13 least13 part13 of13 the13 answer13

How13 then13 do13 we13 overlay13 the13 technologies13 (step13 2)13 over13 the13 local13 issues13 (step13 1)13 to13 ensure13 that13 the13 technical13 solution13 finds13 a13 home13 in13 the13 heart13 of13 the13 community13 E-shy‐health13 should13 be13 considered13 as13 another13 community13 activity13 that13 will13 need13 to13 involve13 discussions13 arguments13 and13 deliber-shy‐ations13 E-shy‐health13 should13 thus13 become13 the13 vehicle13 for13 more13 rapid13 and13 more13 structured13 community13 development13 through13 enhanced13 communications13 and13 process13 documentation13 This13 becomes13 more13 apparent13 with13 the13 use13 of13 mobile13 phones13 for13 health-shy‐related13 concerns13 such13 as13 announcements13 for13 community13 meetings13 reminders13 for13 vaccinations13 and13 prenatal13 check-shy‐ups13 It13 also13 involves13 gathering13 the13 health13 volunteers13 and13 workers13 regularly13 to13 attend13 e-shy‐learning13 sessions13 on13 community13 health13 development13

In13 the13 third13 National13 Telemedicine13 Centre13 project13 studied13 by13 Marcelo13 (2009)13 ten13 medical13 centres13 were13 given13 hardware13 and13 Internet13 access13 to13 enable13 them13 to13 contact13 experts13 No13 doctors13 used13 the13 service13 Centre13 staff13 analysed13 the13 situation13 from13 the13 doctor13 perspective13 and13 understood13 the13 complex13 workflow13 required13 and13 why13 it13 was13 not13 working13 for13 the13 doc-shy‐tors13 They13 then13 modified13 the13 model13 to13 one13 in13 which13 doctors13 used13 their13 existing13 mobile13 phones13 to13 text13 queries13 The13 project13 resources13 then13 supplemented13 the13 doctorsrsquo13 mobile13 phone13 plans13 to13 fund13 voice13 calls13 to13 experts13 as13 appropriate13 Over13 a13 six-shy‐month13 period13 more13 than13 30013 referrals13 were13 received13 from13 4413 doctors13 in13 remote13 areas13

The13 education13 manager13 from13 Tokelau13 recommended13 that13 the13 research13 team13 for13 this13 study13 find13 out13 what13 community13 leaders13 see13 as13 their13 role13 in13 supporting13 these13 types13 of13 service13 In13 recognising13 the13 potential13 of13 the13 Internet13 the13 Samoan13 doctor13 noted13 the13 need13 for13 a13 culture13 change13 in13 the13 villages13 13

ldquoYes13 I13 see13 the13 need13 for13 up-shy‐to-shy‐date13 information13 for13 the13 onward13 progress13 of13 health13 work13 and13 I13 also13 see13 that13 Samoa13 is13 only13 a13 village13 that13 is13 slowly13 get-shy‐ting13 to13 terms13 with13 the13 use13 of13 the13 Internet13 especially13 in13 the13 villages13 It13 wasnrsquot13 so13 long13 ago13 that13 we13 still13 had13 black13 boards13 in13 our13 schools13 and13 churches13 In13 fact13 I13 think13 that13 some13 schools13 still13 have13 this13 In13 terms13 of13 long-shy‐term13 sustainability13 the13 Internet13 needs13 to13 come13 with13 a13 culture13 change13 in13 the13 villages13 The13 farsquoa13 [The13 Samoan13 Way]113 in13 Samoa13 is13 still13 a13 very13 important13 method13 of13 learning13 and13 teaching13 in13 every13 area13 of13 health13 and13 even13 the13 traditional13 ways13 of13 health13 are13 upheld13 in13 the13 communities13 like13 the13 fofo13 [massage]13 and13 the13 tatalo13 [prayer]13 There13 is13 a13 strong13 belief13 in13 the13 medically13 trained13 doctor13 and13 nurse13 and13 there13 is13 also13 a13 lot13 of13 trust13 in-shy‐vested13 by13 the13 people13 in13 us13 and13 we13 are13 responsible13 for13 delivering13 the13 right13 service13 in13 their13 eyesrdquo13 (Doctor13 Samoa)13

13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13

113 In13 Samoa13 the13 farsquoa13 ldquorefers13 to13 an13 all-shy‐encompassing13 traditional13 system13 of13 behaviour13 and13 responsibilities13 that13 spells13 out13

each13 personrsquos13 relationship13 to13 one13 another13 and13 to13 persons13 holding13 positions13 of13 authorityrdquo13 (Wikipedia)13


4013

A Samoan community case study The13 second13 part13 of13 the13 research13 was13 to13 seek13 to13 understand13 in13 more13 detail13 a13 communityrsquos13 needs13 in13 regard13 to13 digital13 literacy13 in13 health13 The13 research13 team13 chose13 Samoa13 because13 of13 the13 Pacific13 team13 memberrsquos13 strong13 links13 to13 this13 country13 but13 believe13 the13 case13 study13 could13 be13 relevant13 in13 other13 Pacific13 nations13 which13 have13 similar13 considerations13 Goshen13 Trust13 Samoa13 Mental13 Health13 Service13 was13 chosen13 for13 the13 case13 study13 on13 the13 basis13 of13 personal13 networks13

Goshen13 is13 located13 a13 few13 minutesrsquo13 drive13 from13 the13 city13 of13 Apia13 The13 Goshen13 Trust13 Samoa13 Mental13 Health13 Service13 was13 established13 November13 200913 This13 non-shy‐governmental13 organi-shy‐sation13 supports13 people13 who13 experience13 mental13 ill13 health13 in13 Samoa13 Ten13 years13 ago13 Tutogi13 Savea-shy‐Torsquoo13 the13 current13 managing13 director13 had13 the13 vision13 for13 the13 service13 She13 had13 been13 part13 of13 the13 team13 working13 out13 of13 the13 Pacific13 Islands13 mental13 health13 service13 Isa13 Lei13 within13 the13 Waitemata13 Health13 District13 Health13 Service13 New13 Zealand13 13

Goshen13 was13 launched13 in13 Samoa13 by13 staff13 from13 the13 Penina13 Health13 Trust13 of13 South13 Auckland13 The13 Board13 is13 made13 up13 of13 a13 secretary13 Dr13 Sarsquoilau13 Sauni13 two13 psychiatrists13 Dr13 Frances13 Ag-shy‐new13 and13 Dr13 Ian13 Parkins13 and13 two13 family13 representatives13 Goshen13 is13 funded13 by13 gifts13 from13 the13 Samoan13 community13 Recently13 the13 Samoan13 government13 funded13 an13 office13 block13 and13 residential13 dwellings13 to13 assist13 in13 the13 set-shy‐up13 The13 Samoa13 International13 Finance13 Association13 provided13 a13 vehicle13 for13 the13 service13 to13 use13 13

Goshen13 is13 breaking13 new13 ground13 in13 two13 ways13 by13 focusing13 on13 mental13 health13 which13 is13 not13 yet13 a13 targeted13 visible13 health13 area13 in13 Samoa13 and13 by13 developing13 an13 integrated13 model13 that13 relies13 on13 strong13 ongoing13 relationships13 between13 existing13 providers13 and13 that13 values13 both13 formal13 and13 community-shy‐based13 provision13 13

The13 service13 provides13 advice13 to13 clients13 and13 their13 families13 on13 mental13 health13 issues13 follow-shy‐ing13 through13 with13 information13 that13 is13 required13 for13 their13 overall13 health13 needs13 Tutogi13 believes13 that13 the13 health13 information13 that13 the13 community13 needs13 can13 be13 found13 through13 community-shy‐based13 and13 more13 formal13 health13 services13 across13 Samoa13 Goshenrsquos13 planned13 ap-shy‐proach13 is13 to13 offer13 seamless13 medical13 care13 through13 coordinating13 these13 two13 siloed13 services13 presently13 available13 in13 Samoa13 She13 says13 that13 you13 can13 have13 almost13 any13 type13 of13 care13 in13 Samoa13 if13 you13 are13 prepared13 to13 pay13 for13 it13 and13 know13 someone13 close13 to13 where13 it13 can13 be13 bought13 Goshenrsquos13 vision13 is13 that13 government13 will13 equally13 value13 and13 therefore13 fund13 the13 community13 health13 services13 as13 well13 as13 the13 more13 formal13 medical13 ones13 Goshen13 has13 a13 resi-shy‐dential13 service13 which13 currently13 has13 one13 client13 and13 a13 service13 visiting13 clients13 which13 is13 currently13 provided13 for13 free13 Goshen13 has13 six13 full-shy‐time13 volunteer13 staff13 who13 are13 committed13 to13 the13 mental13 health13 cause13 13

Tutogi13 has13 spent13 the13 last13 year13 visiting13 clinical13 services13 in13 Samoa13 calling13 on13 church13 organi-shy‐sations13 knocking13 on13 fundersrsquo13 doors13 and13 networking13 with13 the13 Prime13 Minister13 and13 the13 Head13 of13 State13 of13 Samoa13 to13 introduce13 the13 Goshen13 service13 and13 promote13 its13 profile13 and13 ser-shy‐vice13 provision13 Although13 it13 has13 been13 hard13 Tutogirsquos13 success13 can13 be13 directly13 attributed13 to13 the13 relationships13 she13 has13 fostered13 since13 she13 first13 began13 the13 service13 She13 believes13 it13 is13 ldquowho13 you13 know13 in13 Samoa13 not13 what13 you13 knowrdquo13 Through13 her13 relationship13 building13 she13 now13 has13 high-shy‐level13 support13 for13 funding13 applications13 from13 the13 Prime13 Minister13 and13 the13 Head13 of13 State13 For13 example13 Tutogi13 has13 now13 applied13 to13 the13 Ministry13 of13 Health13 and13 the13 National13 Health13 Service13 of13 Samoa13 for13 a13 fairly13 large13 amount13 of13 funding13 to13 assist13 in13 the13 next13 stage13 of13 expanding13 the13 service13 employing13 more13 staff13 and13 staff13 training13 Awareness13 and13 understanding13 of13 medication13 and13 its13 uses13 are13 important13 areas13 for13 staff13 development13 She13


4113

has13 approached13 pharmacies13 in13 New13 Zealand13 and13 Australia13 to13 support13 their13 work13 Penina13 Trust13 in13 South13 Auckland13 New13 Zealand13 holds13 regular13 fundraising13 events13 to13 assist13 the13 service13 with13 high-shy‐level13 support13 from13 New13 Zealandrsquos13 top13 advisor13 in13 mental13 health13

Tutogi13 has13 presented13 the13 National13 Health13 Service13 of13 Samoa13 with13 a13 draft13 proposal13 She13 hopes13 that13 NZAID13 and13 AusAID13 will13 be13 partners13 The13 current13 Minister13 of13 Health13 in13 Samoa13 is13 keen13 for13 Goshen13 to13 get13 off13 the13 ground13 and13 be13 sustained13 into13 the13 future13 Often13 itrsquos13 the13 track13 record13 that13 has13 to13 be13 visible13 before13 a13 funder13 will13 back13 an13 initiative13 But13 Tutogi13 has13 chosen13 the13 Pacific13 relationship-shy‐focused13 way13 for13 her13 fundraising13 approach13 which13 she13 believes13 is13 appropriate13 for13 the13 community13 the13 service13 and13 the13 clients13 13

A13 lot13 of13 emphasis13 is13 placed13 on13 the13 traditional13 knowledge13 of13 healers13 in13 the13 community13 par-shy‐ticularly13 in13 regard13 to13 mental13 health13 Samoa13 has13 its13 own13 definitions13 of13 things13 such13 as13 schizophrenia13 bipolar13 disorder13 and13 stress13 Goshen13 believes13 in13 correct13 diagnosis13 of13 the13 client13 and13 that13 appropriate13 medication13 alongside13 prayer13 and13 community13 support13 is13 the13 right13 way13 to13 offer13 true13 care13 for13 a13 client13 Where13 the13 client13 needs13 respite13 this13 is13 often13 provided13 in13 the13 family13 home13 with13 lots13 of13 advice13 from13 Goshen13 and13 support13 for13 the13 family13 In13 contrast13 Western13 models13 often13 offer13 respite13 in13 isolation13 from13 family13 under13 the13 watchful13 eye13 of13 an13 on-shy‐duty13 clin-shy‐ician13

Tutogi13 believes13 relationship-shy‐building13 is13 a13 universal13 principle13 in13 the13 Pacific13 and13 that13 face-shy‐to-shy‐face13 relating13 is13 important13 when13 working13 across13 any13 services13 Goshen13 is13 pioneering13 this13 in13 the13 mental13 health13 area13 building13 upon13 the13 integrity13 and13 passion13 of13 the13 staff13 and13 valuing13 these13 skills13 in13 all13 staff13 in13 addition13 to13 the13 formal13 qualifications13 of13 some13 staff13 13

Digital13 literacy13 is13 a13 long13 way13 from13 services13 like13 Goshen13 in13 the13 sense13 that13 Samoa13 is13 in13 many13 parts13 still13 very13 traditional13 in13 its13 information13 culture13 The13 indigenous13 still13 works13 and13 the13 farsquoa13 Samoa13 is13 strong13 The13 practice13 of13 farsquoa13 Samoa13 is13 based13 on13 the13 village13 infrastructure13 of13 matai13 (chief)13 and13 family13 relationships13 Knowledge13 and13 information13 is13 passed13 through13 this13 channel13 of13 filters13 and13 conduits13 according13 to13 the13 locals13 in13 the13 village13 13

Tutogi13 believes13 that13 the13 Internet13 could13 be13 a13 valuable13 tool13 for13 Goshen13 in13 providing13 access13 to13 medication13 information13 hospital13 records13 client13 histories13 illness13 identification13 medical13 ad-shy‐vice13 and13 connections13 through13 social13 networking13 Goshen13 could13 offer13 further13 study13 through13 their13 relationships13 with13 education13 providers13 in13 New13 Zealand13 and13 the13 University13 of13 Samoa13 and13 University13 of13 the13 South13 Pacific13 Building13 on13 her13 relational13 approach13 and13 existing13 strong13 con-shy‐nections13 with13 churches13 Tutogi13 sees13 potential13 for13 Goshen13 workers13 and13 volunteers13 to13 use13 pastorsrsquo13 computers13 She13 also13 believes13 that13 the13 training13 she13 received13 in13 New13 Zealand13 has13 made13 the13 biggest13 difference13 in13 her13 attitude13 and13 application13 to13 online13 tools13 and13 recognises13 the13 importance13 of13 providing13 training13 along13 with13 the13 tools13 13

From13 this13 study13 we13 can13 conclude13 that13 for13 digital13 health13 to13 enable13 community13 health13 work-shy‐ers13 at13 Goshen13 to13 do13 their13 job13 better13 the13 following13 elements13 need13 to13 be13 present13

bull adequate13 resourcing13 which13 depends13 on13 long-shy‐term13 relationships13 between13 various13 Gos-shy‐hen13 staff13 and13 funders13



bull training13 for13 staff13


4213

Where international organisations such as COL might add value Recommendations As13 previously13 stated13 this13 research13 had13 two13 aims13

bull to13 provide13 a13 broad13 overview13 of13 current13 initiatives13 in13 digital13 literacy13 in13 the13 health13 sector13 and13 13

bull to13 identify13 possible13 gaps13 in13 or13 needs13 for13 capability13 building13 where13 the13 Commonwealth13 of13 Learning13 (COL)13 may13 be13 able13 to13 add13 value13

The13 previous13 sections13 of13 this13 report13 address13 the13 first13 aim13 This13 section13 considers13 the13 learning13 from13 the13 previous13 sections13 to13 address13 the13 second13 aim13 to13 identify13 possible13 gaps13 in13 or13 needs13 for13 capability13 building13 where13 international13 organisations13 such13 as13 COL13 may13 be13 able13 to13 add13 value13 13

This13 section13 proposes13 five13 options13 based13 on13 the13 opportunities13 identified13 in13 the13 earlier13 sections13 These13 options13 are13 not13 mutually13 exclusive13 13

Fifteen13 years13 ago13 Gilster13 (1997)13 wrote13

The13 skills13 of13 the13 digitally13 literate13 are13 becoming13 as13 necessary13 as13 a13 driverrsquos13 license13 The13 Internet13 is13 the13 fastest13 growing13 medium13 in13 history13 mdash13 like13 it13 or13 not13 it13 will13 affect13 you13 and13 those13 around13 you13 at13 home13 and13 on13 the13 job13 from13 the13 merging13 of13 your13 television13 setrsquos13 images13 with13 network13 data13 to13 the13 emergence13 of13 communities13 of13 users13 whose13 activities13 will13 change13 the13 shape13 of13 commerce13 and13 education13 The13 Netrsquos13 growing13 universality13 will13 create13 priceless13 resources13 for13 learning13 and13 self-shy‐advancement13 If13 these13 wonrsquot13 overwhelm13 your13 life13 over-shy‐night13 they13 will13 change13 it13 subtly13 continually13 and13 with13 irresistible13 force13

For13 many13 of13 us13 in13 the13 developed13 world13 these13 words13 would13 not13 have13 resonated13 when13 Gilster13 wrote13 them13 but13 they13 have13 proven13 true13 in13 the13 last13 decade13 However13 it13 is13 clear13 that13 this13 has13 not13 yet13 happened13 for13 community13 health13 workers13 in13 the13 Pacific13 13

This13 research13 shows13 that13 community13 health13 workers13 in13 the13 Pacific13 play13 an13 important13 role13 in13 their13 countriesrsquo13 health13 systems13 but13 do13 so13 with13 minimal13 access13 to13 or13 use13 of13 online13 information13 and13 support13 Instead13 they13 rely13 on13 traditional13 indigenous13 ways13 of13 seeking13 health13 information13 and13 traditional13 knowledge13 The13 community13 health13 workers13 surveyed13 were13 very13 aware13 of13 their13 diffi-shy‐culty13 accessing13 the13 Internet13 which13 was13 primarily13 a13 result13 of13 high13 cost13 However13 they13 appeared13 less13 aware13 of13 what13 they13 might13 be13 missing13 through13 this13 lack13 of13 access13 Their13 present13 use13 of13 tech-shy‐nology13 centres13 on13 irregular13 searches13 for13 online13 information13 and13 visits13 to13 trusted13 websites13 which13 is13 not13 surprising13 given13 the13 cost13 and13 difficulty13 of13 access13 The13 people13 interviewed13 did13 not13 mention13 accessing13 the13 websites13 that13 the13 research13 team13 believes13 could13 be13 relevant13 for13 Pacific13 community13 health13 workers13

Regional13 and13 national13 government13 policies13 tend13 to13 identify13 the13 importance13 of13 both13 community13 health13 workers13 and13 of13 ICT13 for13 health13 However13 the13 research13 team13 did13 not13 find13 any13 policy13 that13 linked13 these13 two13 priorities13 13


4313

CO MMU NI TY-RELEV ANT PRO J ECTS

This13 research13 shows13 very13 clearly13 that13 digital13 health13 projects13 must13 be13 relevant13 to13 the13 community13 and13 have13 ongoing13 buy-shy‐in13 from13 community13 leaders13 to13 succeed13 Pilot13 approaches13 need13 to13 be13 co-shy‐developed13 with13 community13 health13 workers13 and13 relevant13 community13 members13 including13 lead-shy‐ers13 building13 on13 their13 felt13 needs13 and13 the13 technologies13 with13 which13 they13 are13 already13 comfortable13 and13 include13 training13 methods13 that13 build13 confidence13 rather13 than13 fear13 (Marcelo13 2009)13 Any13 of13 the13 options13 below13 need13 to13 start13 with13 community13 involvement13 and13 continue13 with13 community13 in-shy‐volvement13 through13 design13 development13 implementation13 and13 evaluation13 13

DI STANCE LEARNI NG

A13 global13 focus13 is13 on13 the13 potential13 of13 distance13 learning13 to13 help13 meet13 the13 need13 to13 train13 large13 num-shy‐bers13 of13 community13 health13 workers13 including13 in13 the13 Pacific13 (Global13 Health13 Workforce13 Alliance13 200813 Joynes13 2011)13 COL13 exists13 to13 ldquoencourage13 the13 development13 and13 sharing13 of13 open13 learningdistance13 education13 knowledge13 resources13 and13 technologiesrdquo13 (Commonwealth13 of13 Learning13 nd)13 13

A13 possible13 role13 would13 be13 for13 COL13 to13 work13 with13 POLHN13 to13 create13 pilot13 and13 evaluate13 a13 distance13 learning13 experience13 targeting13 community13 health13 workers13 Some13 of13 POLHNrsquos13 courses13 are13 already13 focused13 on13 community13 health13 workers13 The13 focus13 in13 the13 project13 would13 be13 looking13 at13 ldquowhat13 are13 the13 needs13 of13 the13 community13 and13 then13 tailoring13 the13 training13 in13 helping13 them13 find13 the13 help13 that13 they13 needrdquo13 (Director13 POLHN)13 This13 project13 could13 use13 existing13 resources13 where13 possible13 to13 keep13 costs13 down13 The13 learning13 design13 would13 need13 to13 take13 into13 account13 the13 existing13 low13 levels13 of13 digi-shy‐tal13 literacy13 the13 present13 unreliable13 and13 expensive13 Internet13 infrastructure13 and13 the13 research13 on13 barriers13 to13 successful13 distance13 learning13 in13 the13 Pacific13 Through13 its13 learning13 centres13 POLHN13 can13 alleviate13 some13 of13 these13 factors13 but13 relying13 solely13 on13 POLHNrsquos13 centres13 would13 significantly13 de-shy‐crease13 access13 so13 the13 project13 would13 need13 to13 get13 the13 right13 balance13

The13 research13 team13 believes13 that13 it13 would13 be13 important13 for13 COL13 to13 be13 involved13 beyond13 develop-shy‐ing13 the13 learning13 materials13 to13 learn13 from13 the13 implementation13 phase13 what13 an13 appropriate13 approach13 is13 in13 rural13 and13 remote13 villages13 of13 the13 Pacific13 However13 once13 designed13 and13 developed13 the13 resources13 could13 be13 made13 available13 online13 for13 other13 countries13 to13 customise13 to13 meet13 their13 community13 health13 worker13 training13 needs13 13

MO B I LE LEARNI NG

The13 lack13 of13 reliable13 or13 affordable13 Internet13 access13 especially13 in13 rural13 villages13 and13 remote13 islands13 suggests13 that13 it13 may13 be13 too13 soon13 to13 consider13 Internet-shy‐based13 pilot13 activities13 However13 as13 the13 number13 of13 mobile13 phone13 users13 in13 several13 countries13 is13 comparable13 to13 that13 in13 Australia13 and13 New13 Zealand13 a13 mobile-shy‐based13 activity13 seems13 appropriate13 Projects13 in13 Ghana13 India13 Rwanda13 and13 the13 Philippines13 suggest13 that13 this13 technology13 has13 the13 potential13 to13 assist13 community13 support13 workers13 in13 their13 work13 Unfortunately13 the13 research13 team13 did13 not13 identify13 these13 projects13 until13 late13 in13 the13 research13 so13 did13 not13 include13 a13 question13 to13 understand13 mobile13 phone13 use13 in13 the13 survey13 13

A13 possible13 role13 for13 COL13 is13 to13 work13 with13 a13 community13 provider13 to13 co-shy‐design13 develop13 implement13 and13 evaluate13 a13 project13 using13 mobile13 phones13 COL13 could13 use13 its13 networks13 to13 better13 understand13 what13 has13 and13 has13 not13 worked13 in13 other13 countries13 with13 mobile13 phone13 projects13 to13 enhance13 health13 outcomes13 as13 well13 as13 its13 distance13 learning13 expertise13 to13 design13 a13 workable13 solution13 in13 response13 to13 the13 communityrsquos13 and13 providerrsquos13 felt13 needs13

The13 Goshen13 case13 study13 shows13 that13 the13 leader13 of13 at13 least13 one13 community13 provider13 believes13 in13 the13 potential13 of13 technology13 to13 improve13 its13 service13 The13 study13 identified13 that13 at13 least13 four13 ele-shy‐ments13 would13 be13 necessary13 for13 a13 pilot13 to13 succeed13


4413

bull adequate13 resourcing13 which13 depends13 on13 long-shy‐term13 relationships13 between13 various13 Goshen13 staff13 and13 funders13




Interestingly13 Digicel13 the13 innovative13 mobile13 phone13 company13 mentioned13 above13 sponsors13 the13 Digicel13 Medical13 Outreach13 programme13 through13 which13 200013 patients13 have13 been13 screened13 and13 offered13 medical13 supplies13 However13 this13 programme13 does13 not13 appear13 to13 use13 mobile13 technology13 Rather13 volunteers13 run13 free13 one-shy‐day13 clinics13 in13 remote13 locations13 They13 may13 be13 interested13 in13 partnering13 in13 a13 project13

SU PERV I SI O N

Proper13 supervision13 is13 a13 key13 to13 community13 health13 worker13 success13 However13 it13 is13 proving13 chal-shy‐lenging13 to13 develop13 and13 implement13 an13 effective13 affordable13 model13 for13 the13 Pacific13 Because13 ICT13 supports13 learning13 and13 connection13 it13 offers13 the13 potential13 to13 be13 an13 essential13 ingredient13 within13 an13 innovative13 supervision13 model13 Given13 the13 low13 digital13 literacy13 of13 community13 support13 workers13 it13 is13 likely13 that13 the13 model13 would13 need13 to13 use13 a13 blend13 of13 face-shy‐to-shy‐face13 and13 online13 interactions13 Com-shy‐munity13 health13 workers13 supervisors13 and13 community13 leaders13 would13 need13 to13 co-shy‐develop13 this13 pilot13

LO CAL CO NTENT DEV ELO PMENT

Appropriate13 use13 of13 language13 and13 culture13 are13 important13 for13 effective13 communication13 between13 health13 professionals13 and13 patients13 (Singleton13 amp13 Krause13 200913 Underwood13 et13 al13 200713 Nguyen13 amp13 Bowman13 2007)13 It13 is13 becoming13 increasingly13 possible13 for13 untrained13 individuals13 to13 create13 multi-shy‐media13 resources13 using13 readily13 available13 software13 and13 upload13 them13 to13 the13 ldquoCloudrdquo13 as13 already13 demonstrated13 in13 projects13 in13 the13 Pacific13 (Robbins13 200613 Harris13 2007)13 13

A13 possible13 role13 for13 COL13 is13 to13 lead13 a13 local13 content13 development13 project13 to13 help13 meet13 a13 need13 in13 a13 Pacific13 community13 such13 as13 better13 understanding13 of13 a13 health13 issue13 which13 would13 benefit13 from13 resources13 in13 a13 communityrsquos13 first13 language13 or13 use13 of13 media13 such13 as13 telling13 stories13 by13 video13 Community13 radio13 can13 be13 explored13 as13 part13 of13 the13 solution13

CO NCLU SI O N

COLrsquos13 Three-shy‐Year13 Plan13 for13 2009ndash201213 Learning13 for13 Development13 (Commonwealth13 of13 Learning13 2009)13 outlines13 several13 initiatives13 and13 outcomes13 relevant13 to13 this13 research13

bull Skills13 development13 Training13 institutions13 and13 civil13 society13 organisations13 have13 the13 policy13 frameworks13 and13 increased13 capacity13 needed13 to13 develop13 and13 deliver13 ODL13 materials13 for13 strengthening13 knowledge13 and13 skills13 in13 both13 formal13 and13 non-shy‐formal13 learning13 environments13

bull Healthy13 communities13 Community13 organisations13 non-shy‐governmental13 organisations13 and13 local13 public13 institutions13 have13 increased13 their13 capacity13 to13 create13 and13 use13 ODL13 materials13 to13 improve13 the13 health13 and13 well-shy‐being13 of13 their13 communities13

bull Integrating13 eLearning13 Institutions13 and13 communities13 use13 digital13 technologies13 to13 design13 and13 develop13 learning13 materials13 and13 models13 that13 are13 made13 available13 where13 possible13 as13 open13 educational13 resources13 and13 to13 provide13 effective13 and13 appropriate13 skills13 training13


4513

In13 light13 of13 these13 priorities13 the13 most13 relevant13 focus13 from13 the13 list13 above13 appears13 to13 be13 open13 and13 distance13 learning13 However13 it13 would13 be13 important13 to13 work13 with13 the13 community13 in13 developing13 this13 mobile13 learning13 could13 be13 a13 part13 of13 it13 and13 it13 could13 involve13 supervision13 and13 local13 content13 development13


4613

References American13 College13 of13 Nurse13 Practitioners13 (2011)13 What13 is13 telehealth13 Retrieved13 from13

httpwwwacnpweborgi4apagesindexcfmpageid=347013

Ashwell13 H13 amp13 Freeman13 P13 (1995)13 The13 clinical13 competency13 of13 community13 health13 workers13 in13 the13 Eastern13 Highlands13 province13 of13 Papua13 New13 Guinea13 PNG13 Medical13 Journal13 38(3)13 198ndash20713

Au13 C13 (2009)13 Assessing13 the13 potential13 needs13 for13 Telehealth13 in13 Papua13 New13 Guinea13 (PNG)13 A13 disser-shy‐tation13 submitted13 in13 partial13 fulfilment13 of13 the13 requirement13 for13 the13 Degree13 of13 Master13 of13 Health13 Sciences13 Retrieved13 from13 httpircanterburyacnzbitstream1009246561thesis_fulltextpdf13

Australian13 Council13 for13 Educational13 Research13 (2010)13 Evaluation13 of13 One13 Laptop13 Per13 Child13 (OLPC)13 Trial13 project13 in13 the13 Solomon13 Islands13 Retrieved13 from13 httpwikilaptoporgimages00bSolomonIslandsOLPCTrialsEvaluationByACER2010pdf13

Brewster13 D13 Pyakalyia13 T13 amp13 OrsquoConnell13 D13 (1993)13 Evaluation13 of13 the13 ARI13 program13 A13 health13 facility13 survey13 in13 Simbu13 Papua13 New13 Guinea13 PNG13 Medical13 Journal13 36(4)13 285ndash29613

Buckingham13 D13 (2006)13 Defining13 digital13 literacy13 What13 do13 young13 people13 need13 to13 know13 about13 digital13 media13 Nordic13 Journal13 of13 Digital13 Literacy13 Retrieved13 from13 httpwwwidunnnotsdk200604defining_digital_literacy_-shy‐_what_do_young_people_need_to_know_about_digitallanguageId=213 13

Chand13 A13 Leeming13 D13 Stork13 E13 Agassi13 A13 amp13 Biliki13 R13 (2005)13 The13 impact13 of13 ICT13 on13 rural13 develop-shy‐ment13 in13 Solomon13 Islands13 The13 PFnet13 case13 Retrieved13 from13 httpwwwuspacfjjicaict_researchdocumentspdf_filespfnet_reportpdf13 13

Chevalier13 C13 Lapo13 A13 OrsquoBrien13 J13 amp13 Wierzba13 T13 (1993)13 Why13 do13 village13 health13 workers13 drop13 out13 World13 Health13 Forum13 14(3)13 258ndash26113

Clements13 J13 Streefland13 P13 amp13 Malau13 13 C13 (2007)13 Supervision13 in13 primary13 health13 care13 mdash13 Can13 it13 be13 carried13 out13 effectively13 in13 developing13 countries13 Current13 Drug13 Safety13 213 19ndash2313

Commonwealth13 of13 Learning13 (2009)13 Learning13 for13 development13 Three-shy‐year13 plan13 for13 2009ndash201213 Retrieved13 from13 httpwwwcolorgSiteCollectionDocuments3YP_09-shy‐12_webpdf13 13

Devi13 S13 (2010)13 Digicel13 spreads13 New13 Zealand13 Pacific13 2313 July13 113 313

Dzenowagis13 J13 (2009)13 Bridging13 the13 digital13 divide13 Linking13 health13 and13 ICT13 policy13 In13 Wootton13 R13 Patil13 N13 Scott13 R13 amp13 Ho13 K13 (Eds)13 Telehealth13 in13 the13 developing13 world13 Retrieved13 from13 httppublicwebsiteidrccaENResourcesPublicationsPagesIDRCBookDetailsaspxPublicationID=5713 13

Fiji13 Ministry13 of13 Health13 (2007)13 Shaping13 Fijirsquos13 health13 Strategic13 plan13 2007ndash201113 Retrieved13 from13 httpwwwwprowhointinternetresourcesashxHSDdocsFiji+MOH+SP+2007-shy‐2011pdf13 13

Fiji13 Ministry13 of13 Health13 (2011)13 Project13 for13 strengthening13 the13 need-shy‐based13 in-shy‐service13 training13 for13 community13 health13 nurses13 Japan13 International13 Cooperation13 Agency13 13

Finau13 S13 Dever13 G13 Finau13 E13 amp13 Yano13 V13 (2000)13 Monolingual13 monologue13 Regional13 issues13 of13 pro-shy‐fessional13 communication13 from13 Pacific13 Health13 Dialog13 Pacific13 Health13 Dialog13 7(2)13 127ndash13513 Retrieved13 from13 httpwwwspcintphsEnglishPublicationsPHDPHDpages127-shy‐135pdf13 13


4713

Fotu13 K13 Moodie13 M13 Mavoa13 H13 Pomana13 S13 Schultz13 J13 amp13 Swinburn13 B13 (2011)13 Process13 evaluation13 of13 a13 community-shy‐based13 adolescent13 obesity13 prevention13 project13 in13 Tonga13 BMC13 Public13 Health13 1113 28413 Retrieved13 from13 httpwwwbiomedcentralcom1471-shy‐24581128413

Gardner13 K13 Bailie13 R13 Si13 D13 OrsquoDonoghue13 L13 Kennedy13 C13 Liddle13 H13 Cox13 R13 Kwedza13 R13 Fittock13 M13 Hains13 J13 Dowden13 M13 Connors13 C13 Burke13 H13 amp13 Beaver13 C13 (2011)13 Reorienting13 primary13 health13 care13 for13 addressing13 chronic13 conditions13 in13 remote13 Australia13 and13 the13 South13 Pacific13 Review13 of13 evidence13 and13 lessons13 from13 an13 innovative13 quality13 improvement13 process13 Australian13 Journal13 of13 Rural13 Health13 19111ndash11713 13

Garner13 P13 amp13 Thomason13 J13 (1993)13 Setting13 standards13 for13 primary13 health13 services13 Tropical13 Doctor13 23(4)13 147ndash14813

Gilster13 P13 (1997)13 Digital13 literacy13 Toronto13 Canada13 John13 Wiley13 amp13 Sons13

Global13 Health13 Workforce13 Alliance13 (2008)13 Scaling13 up13 saving13 lives13 Task13 force13 for13 scaling13 up13 edu-shy‐cation13 and13 training13 for13 health13 workers13 Retrieved13 from13 httpwwwwhointworkforcealliancedocumentsGlobal_Health20FINAL20REPORTpdf13

Government13 of13 Papua13 New13 Guinea13 (2010)13 Transforming13 our13 health13 system13 towards13 Health13 Vision13 205013 National13 health13 plan13 2011ndash202013 Volume13 113 Policies13 and13 strategies13 Retrieved13 from13 httpzanggomfileswordpresscom201010pngnhp_vol1_final300dpi_020710pdf13 (Not13 retrievable13 from13 httpwwwhealthgovpg)13

Harris13 U13 (2007)13 Community13 informatics13 and13 the13 power13 of13 participation13 Pacific13 Journalism13 Re-shy‐view13 13(2)13 29ndash4513

Health13 Research13 Council13 of13 New13 Zealand13 (2005)13 The13 Health13 Research13 Council13 of13 New13 Zealand13 guidelines13 on13 Pacific13 health13 research13 Retrieved13 from13 httpwwwhrcgovtnzassetspdfspublicationsMay20200520Pac20Guidelinespdf13 13

Health13 Research13 Council13 of13 New13 Zealand13 (2011)13 Pacific13 research13 frameworks13 at13 the13 HRC13 Re-shy‐trieved13 from13 httpwwwhrcgovtnzrootPacific20Health20ResearchAbout20Pacific20Health20Research20at20the20HRCPacific_research_frameworks_at_the_HRChtml13 13

Herman13 F13 (2010)13 The13 Pacific13 right13 to13 know13 in13 the13 digital13 age13 Pacific13 Journalism13 Review13 16(2)13 51ndash5513

Higa13 C13 (2007)13 ICT13 capacity13 and13 human13 resource13 development13 in13 island13 economies13 Developing13 Human13 Resources13 in13 the13 Pacific13 14(1)13 98ndash10113 13

Hogan13 R13 (2009)13 Attitudes13 of13 indigenous13 peoples13 toward13 distance13 learning13 in13 the13 South13 Pacific13 An13 empirical13 study13 In13 Siemens13 G13 amp13 Fulford13 C13 (Eds)13 Proceedings13 of13 World13 Conference13 on13 Educational13 Multimedia13 Hypermedia13 and13 Telecommunications13 200913 (pp13 1064ndash1072)13

Hughes13 F13 Finlayson13 M13 Firkin13 P13 Funk13 M13 Drew13 N13 Barrett13 T13 Wang13 X13 amp13 Fritsch13 K (2005)13 Situational13 analysis13 of13 mental13 health13 needs13 and13 resources13 in13 Pacific13 Island13 countries13 Re-shy‐trieved13 from13 httpwwwwhointmental_healthpolicypimhnetPacific_islands_needs_assessmentspdf13

Hutak13 M13 amp13 Thomson13 I13 (2010)13 The13 role13 of13 ICTs13 in13 teaching13 and13 learning13 Best13 practice13 in13 Pacific13 education13 In13 Puamau13 P13 amp13 Haursquoofa13 B13 (Eds)13 Pacific13 Education13 Series13 No13 913 Best13 practice13 in13 Pacific13 education13 Learning13 with13 PRIDE13 Suva13 Fiji13 Institute13 of13 Education13 University13 of13 the13 South13 Pacific13 13

Jones13 A13 (1993)13 Popular13 participation13 in13 community13 health13 programmes13 World13 Health13 Forum13 14(2)13 163ndash16713


4813

Jones-shy‐Kavalier13 B13 R13 amp13 Flannigan13 S13 L13 (2006)13 Connecting13 the13 digital13 dots13 Literacy13 of13 the13 21st13 cen-shy‐tury13 EDUCAUSE13 Quarterly13 29(2)13 Retrieved13 from13 httpwwweducauseeduEDUCAUSE+QuarterlyEDUCAUSEQuarterlyMagazineVolumConnectingtheDigitalDotsLitera15739513

Joynes13 C13 (2011)13 Distance13 learning13 for13 health13 What13 works13 A13 global13 review13 of13 accredited13 post-shy‐qualification13 training13 programmes13 for13 health13 workers13 in13 low13 and13 middle13 income13 countries13 London13 International13 Development13 Centre13 Retrieved13 from13 httpwwwlidcorguk_assetsDL4H20Report20FullPDF13 13

Khazei13 A13 Jarvis-shy‐Selinger13 S13 Ho13 K13 amp13 Lee13 A13 (2005)13 An13 assessment13 of13 the13 telehealth13 needs13 and13 health-shy‐care13 priorities13 of13 Tanna13 Island13 A13 remote13 under-shy‐served13 and13 vulnerable13 population13 Journal13 of13 Telemedicine13 and13 Telecare13 1113 35ndash4013

Kickbusch13 I13 (2011)13 Health13 literacy13 Addressing13 the13 health13 and13 education13 divide13 Health13 Promo-shy‐tion13 International13 16(3)13 289ndash29713 Retrieved13 from13 httpheaprooxfordjournalsorgcontent163289full13 13

Kiribati13 Ministry13 of13 Health13 and13 Medical13 Services13 (2008)13 Ministry13 of13 Health13 and13 Medical13 Services13 strategic13 plan13 2008ndash201113 Retrieved13 from13 httpwwwwprowhointinternetresourcesashxHSDdocsKiribati+health+planpdf13 13

Koloto13 A13 H13 Katoanga13 A13 N13 amp13 Tatila13 L13 U13 (2006)13 Critical13 success13 factors13 for13 effective13 use13 of13 e-shy‐learning13 by13 Pacific13 learners13 Retrieved13 from13 httpakoaotearoaacnzdownloadngfilegroup-shy‐996n4006-shy‐critical-shy‐success-shy‐factors-shy‐for-shy‐effective-shy‐use-shy‐of-shy‐e-shy‐learning-shy‐by-shy‐pacific-shy‐learnerspdf13 13

Lemming13 D13 (2007)13 The13 islands13 of13 wisdom13 (and13 learning)13 The13 role13 of13 ICT13 and13 distance13 mode13 in13 education13 reform13 in13 Solomon13 Islands13 The13 case13 of13 the13 distance13 learning13 centres13 project13 Re-shy‐trieved13 from13 httppaddleuspacfjcgi-shy‐binpaddlee=d-shy‐010off-shy‐paddle-shy‐-shy‐00-shy‐1-shy‐-shy‐0-shy‐-shy‐-shy‐0-shy‐10-shy‐TX-shy‐-shy‐4-shy‐-shy‐-shy‐-shy‐-shy‐-shy‐-shy‐0-shy‐11l-shy‐-shy‐11-shy‐en-shy‐50-shy‐-shy‐-shy‐20-shy‐fsm-shy‐-shy‐-shy‐00-shy‐3-shy‐1-shy‐000-shy‐-shy‐0-shy‐0-shy‐11-shy‐0utfZz-shy‐8-shy‐00ampa=fileampd=pifs04713 13

Lewis13 D13 Hodge13 N13 Gamage13 D13 amp13 Whittaker13 M13 (2011)13 Understanding13 the13 role13 of13 technology13 in13 health13 information13 systems13 HIS13 Knowledge13 Hubrsquos13 Working13 Paper13 Series13 School13 of13 Popula-shy‐tion13 Health13 University13 of13 Queensland13 Retrieved13 from13 httpwwwuqeduauhishubdocsWP_17pdf13 13

Marcelo13 A13 (2009)13 Telemedicine13 in13 developing13 countries13 Perspectives13 from13 the13 Philippines13 In13 Wootton13 R13 Patil13 N13 Scott13 R13 amp13 Ho13 K13 (Eds)13 Telehealth13 in13 the13 developing13 world13 Retrieved13 from13 httppublicwebsiteidrccaENResourcesPublicationsPagesIDRCBookDetailsaspxPublicationID=5713

Mills13 G13 (2002)13 Which13 way13 for13 welfare13 in13 the13 South13 Pacific13 International13 Social13 Work13 45(2)13 239ndash25113

Nabobo-shy‐Baba13 U13 (2007)13 Teacher13 education13 for13 new13 times13 Reconceptualising13 pedagogy13 and13 learning13 in13 the13 Pacific13 In13 Puamau13 P13 (Ed)13 Pacific13 voices13 ndash13 teacher13 education13 on13 the13 move13 Retrieved13 from13 httpwwwuspacfjindexphpid=pac_voices13 13

Negin13 J13 Roberts13 G13 amp13 Lingam13 D13 (2011)13 The13 evolution13 of13 primary13 heath13 care13 in13 Fiji13 Past13 pres-shy‐ent13 and13 future PHD13 16(2)13 13ndash23

Network13 Strategies13 (2010)13 Recommendations13 for13 Digital13 Strategy13 II13 Final13 report13 for13 the13 Pacific13 Islands13 Forum13 Secretariat13 1113 June13 201013 Retrieved13 from13 httpwwwforumsecorgfjresourcesuploadsattachmentsdocumentsReview20of20Digital20Strategy_PartBpdf13

Nguyen13 G13 amp13 Bowman13 M13 (2007)13 Culture13 language13 and13 health13 literacy13 Communicating13 about13 health13 with13 Asians13 and13 Pacific13 Islanders13 Family13 Medicine13 39(3)13 208ndash21013


4913

Nutbeam13 D13 (2000)13 Health13 literacy13 as13 a13 public13 health13 goal13 A13 challenge13 for13 contemporary13 health13 education13 and13 communication13 strategies13 into13 the13 21st13 century13 Health13 Promotion13 Interna-shy‐tional13 15(3)13 259ndash26713

Pacific13 Islands13 Forum13 Secretariat13 (2007)13 The13 Pacific13 plan13 for13 strengthening13 regional13 cooperation13 and13 integration13 Pacific13 regional13 digital13 strategy13 Retrieved13 from13 httpwwwforumsecorgfjresourcesuploadsattachmentsdocumentsPacific20Regional20Digital20Strategypdf13 13

Pacific13 Public13 Health13 Surveillance13 Network13 (2011)13 What13 is13 PPHSN13 Retrieved13 from13 httpwwwspcintphsPPHSN13 13

Pryor13 J13 Baravilala13 W13 amp13 Katoanga13 C13 (2000)13 Telehealth13 in13 the13 Pacific13 Islands13 A13 perspective13 and13 update13 from13 the13 Fiji13 School13 of13 Medicine13 Pacific13 Health13 Dialog13 7(2)13 6ndash1013 Retrieved13 from13 httpwwwspcintphsEnglishPublicationsPHDPHDpages6-shy‐10pdf13 13

Republic13 of13 Nauru13 and13 Secretariat13 of13 the13 Pacific13 Community13 (2007)13 The13 Republic13 of13 Nauru13 and13 Secretariat13 of13 the13 Pacific13 Community13 joint13 country13 strategy13 2008ndash201013 Retrieved13 from13 httpwwwspcintsppuimagesstoriesnauru20final202008-shy‐201020jcspdf13 13

Robbins13 C13 (2006)13 Providing13 cultural13 context13 with13 educational13 multimedia13 in13 the13 South13 Pacific13 Educational13 Technology13 amp13 Society13 9(1)13 202ndash21213

Samoa13 Ministry13 of13 Health13 (2007)13 Samoa13 health13 sector13 plan13 2007ndash201513 Retrieved13 from13 httpwwwwprowhointinternetresourcesashxHSDdocsSamoa+HealthSectorPlan07-shy‐15pdf13 13

Secretariat13 of13 the13 Pacific13 Community13 (2005)13 Public13 Health13 Programme13 strategic13 plan13 2006ndash200913 Retrieved13 from13 httpwwwspcintphpindexphpoption=com_docmanamptask=doc_viewampgid=1ampItemid=8313 13

Secretariat13 of13 the13 Pacific13 Community13 (2008)13 Thirty-shy‐eighth13 meeting13 of13 the13 Committee13 of13 Repre-shy‐sentatives13 of13 Governments13 and13 Administrations13 Agenda13 item13 3713 Reaching13 out13 to13 rural13 and13 remote13 communities13 through13 the13 Pacific13 Plan13 Digital13 Strategy13 Retrieved13 from13 httpwwwunohrllsorgUserFilesFileSIDS20documentsPacific20ConnectivityCRGA203820Paper203-shy‐720-shy‐20Digital20Strategypdf13 13

Singleton13 K13 amp13 Krause13 E13 (2009)13 Understanding13 cultural13 and13 linguistic13 barriers13 to13 health13 literacy13 Online13 Journal13 of13 Issues13 in13 Nursing13 14313 Manuscript13 413 Retrieved13 from13 httpwwwnursingworldorgMainMenuCategoriesANAMarketplaceANAPeriodicalsOJINTableofContentsVol142009No3Sept09Cultural-shy‐and-shy‐Linguistic-shy‐Barriers-shy‐aspx13 13

Solomon13 Islands13 Ministry13 of13 Health13 (2006)13 Solomon13 Islands13 national13 health13 strategic13 plan13 2006ndash201013 Retrieved13 from13 httpwwwwprowhointinternetresourcesashxHSDdocsSolomons+MOHMS+Strategic+Plan+for+2006-shy‐2010pdf13 13

Tonga13 Ministry13 of13 Health13 (2008)13 Ministry13 of13 Health13 corporate13 plan13 200809ndash20111213 Re-shy‐trieved13 from13 httpwwwwprowhointinternetresourcesashxHSDdocsTonga+MoH+Corporate+Plan+2008-shy‐09-shy‐2011-shy‐12pdf13 13

Tuvalu13 Ministry13 of13 Health13 (2009)13 Tuvalu13 Ministry13 of13 Health13 strategic13 health13 plan13 2009ndash201813 Retrieved13 from13 httpwwwwprowhointinternetresourcesashxHSDdocsTuvalu+Health+Plan+Final+Unsignedpdf13 13


5013

Underwood13 C13 Serlemitsos13 E13 amp13 Macwangi13 M13 (2007)13 Health13 communication13 in13 multilingual13 contexts13 A13 study13 of13 reading13 preferences13 practices13 and13 proficiencies13 among13 literate13 adults13 in13 Zambia13 Journal13 of13 Health13 Communication13 12(4)13 317ndash33713

United13 Nations13 (2010a)13 Global13 strategy13 for13 womenrsquos13 and13 childrenrsquos13 health13 Retrieved13 from13 httpwwwunorgsghfGlobal_StategyENpdf13

United13 Nations13 (2010b)13 Keeping13 the13 promise13 A13 forward-shy‐looking13 review13 to13 promote13 an13 agreed13 action13 agenda13 to13 achieve13 the13 Millennium13 Development13 Goals13 by13 201513 Retrieved13 from13 httpwwwglobaldialoguefoundationorgfilesCOMM2010-shy‐markeepingthepromisepdf13 13

United13 Nations13 Development13 Program13 (2009)13 Human13 development13 report13 200913 Retrieved13 from13 httphdrstatsundporgenindicators93html13 13

Vanuatu13 Ministry13 of13 Health13 (2004)13 Republic13 of13 Vanuatu13 Master13 health13 services13 plan13 2004ndash200913 Retrieved13 from13 httpwwwwprowhointinternetresourcesashxHSDdocsVanuatu+Health+Master+Plan_LIGHT+VERSIONpdf13 13

Whelan13 R13 (2008)13 Use13 of13 ICT13 in13 the13 South13 Pacific13 Findings13 of13 the13 Pacific13 eLearning13 Observatory13 Distance13 Education13 29(1)13 53ndash7013

Workbase13 (2011)13 Health13 literacy13 statistics13 Retrieved13 from13 httpwwwhealthliteracyorgnzabout-shy‐health-shy‐literacyhealth-shy‐literacy-shy‐statistics13

World13 Health13 Assembly13 (2005)13 Resolution13 582813 eHealth13 May13 200513 Retrieved13 from13 httpappswhointgbebwhapdf_filesWHA58WHA58_28-shy‐enpdf13

World13 Health13 Organization13 (2006)13 Building13 foundations13 for13 eHealth Progress13 of13 member13 states13 Retrieved13 from13 httpwwwwhointgoepublicationsbf_FINALpdf13

World13 Health13 Organization13 (2008)13 Primary13 health13 care13 Fijirsquos13 broken13 dream13 Bulletin13 of13 the13 World13 Health13 Organization13 86(3)13 166ndash16713

13 13

13


5113

Appendix 1 Community health workersrsquo Interview Schedule

1 What13 is13 your13 current13 role13

2 What13 do13 you13 do13 when13 you13 need13 to13 find13 out13 more13 information13 to13 do13 your13 job13 better13

3 If13 you13 use13 online13 access13 for13 information13 tell13 me13 how13 you13 do13 this13

4 Tell13 me13 what13 difference13 this13 made13 to13 the13 community13 you13 serve13

5 If13 you13 donrsquot13 use13 online13 for13 information13 tell13 me13 why13 you13 donrsquot13 and13 what13 you13 would13 like13 to13 change13 about13 this13

6 When13 you13 hear13 the13 words13 ldquodigital13 literacyrdquo13 what13 thoughts13 come13 into13 your13 mind13

7 If13 you13 could13 design13 a13 dream13 of13 best13 digital13 online13 information13 and13 technology13 support13 what13 would13 this13 look13 like13 to13 you13

Appendix 2 Other health workersrsquo Interview Schedule

1 What13 are13 your13 thoughts13 about13 Community13 Support13 Workers13 or13 Community13 Health13 Workers13 using13 online13 services13 for13 their13 roles13 in13 the13 community13

2 What13 in13 particular13 do13 you13 feel13 are13 the13 issues13 or13 challenges13 around13 accessibility13

3 What13 in13 particular13 do13 you13 think13 the13 issues13 or13 challenges13 are13 around13 training13 equip-shy‐ment13 and13 technical13 support13

4 What13 suggestions13 would13 you13 make13 to13 assist13 or13 address13 these13 issues13 andor13 challenges13 13

5 What13 needs13 to13 be13 done13 immediately13 to13 assist13 CSW13 to13 be13 able13 to13 access13 online13 infor-shy‐mation13

6 What13 needs13 to13 be13 done13 in13 the13 future13 to13 keep13 this13 sustainable13

7 How13 do13 you13 see13 the13 traditional13 healersrsquo13 and13 community13 leadersrsquo13 role13 in13 CSW13 work13 in13 information13 gatheringonline13 information13 gathering13

8 What13 other13 information13 would13 help13 our13 research13


5213

Appendix 3 Online resources and communities for Pacific health The13 research13 identified13 the13 following13 websites13 as13 offering13 Pacific-shy‐specific13 health13 information13 that13 can13 be13 used13 by13 community13 health13 workers13 They13 are13 listed13 alphabetically13 with13 a13 brief13 de-shy‐scription13 of13 what13 they13 provide13 and13 comments13 on13 how13 community13 health13 workers13 might13 use13 them13 It13 is13 important13 to13 note13 that13 this13 is13 not13 an13 exhaustive13 list13

Most13 sites13 targeted13 a13 wide13 range13 of13 health13 professionals13 but13 did13 not13 include13 a13 role13 comparable13 to13 community13 health13 workers13 in13 the13 description13 of13 the13 target13 group13 Every13 site13 except13 one13 used13 exclusively13 English13 The13 New13 Zealand13 Ministry13 of13 Healthrsquos13 HealthEd13 website13 provided13 some13 resources13 in13 Pacific13 languages13 mainly13 intended13 for13 use13 in13 the13 community13 13

Generally13 the13 websites13 do13 not13 offer13 RSS13 feeds13 to13 support13 users13 in13 keeping13 up13 to13 date13 with13 changes13 or13 use13 blogs13 or13 other13 social13 media13 to13 add13 life13 to13 the13 sites13 Again13 the13 New13 Zealand13 Min-shy‐istry13 of13 Healthrsquos13 HealthEd13 site13 is13 an13 exception13 providing13 an13 RSS13 feed13 inviting13 sign-shy‐up13 for13 a13 newsletter13 and13 inviting13 users13 to13 assess13 the13 health13 resources13 using13 a13 five-shy‐star13 voting13 system13 No13 sites13 include13 an13 online13 community13 or13 Twitter13 feeds13 to13 help13 visitors13 engage13 with13 the13 target13 community13

The13 websites13 each13 offer13 valuable13 relevant13 information13 but13 the13 small13 subset13 that13 would13 be13 ap-shy‐propriate13 for13 community13 health13 workers13 is13 well13 hidden13 and13 would13 require13 a13 high13 level13 of13 digital13 and13 health13 literacies13 to13 discover13 Most13 sites13 target13 academics13 or13 policy13 makers13 and13 are13 limited13 to13 large13 reports13 or13 articles13 Many13 but13 not13 all13 websites13 provide13 summaries13 of13 articles13 or13 publica-shy‐tions13 to13 help13 users13 assess13 relevance13 The13 only13 site13 that13 focused13 on13 providing13 resources13 to13 support13 those13 in13 the13 community13 to13 develop13 a13 high13 level13 understanding13 of13 a13 range13 of13 health13 is-shy‐sues13 and13 to13 better13 communicate13 this13 to13 their13 communities13 was13 the13 New13 Zealand13 Ministry13 of13 Healthrsquos13 HealthEd13 site13

New Zealand Ministry of Health HealthEd

wwwhealthedgovtnzhome13

This13 website13 hosts13 free13 education13 resources13 some13 of13 which13 are13 targeted13 at13 Pacific13 communities13 and13 are13 therefore13 produced13 in13 Pacific13 languages13 These13 resources13 are13 listed13 by13 topic13 with13 a13 user-shy‐friendly13 search13 by13 language13 option13 The13 site13 aims13 to13 ldquohelp13 you13 to13 make13 informed13 decisions13 for13 yourself13 and13 those13 you13 care13 aboutrdquo13 A13 wide13 range13 of13 resources13 beyond13 PDF13 documents13 are13 included13 such13 as13 videos13 DVDs13 posters13 and13 stickers13 The13 website13 offers13 an13 RSS13 feed13 and13 uses13 a13 five-shy‐star13 resource13 rating13 system13 to13 gather13 feedback13 from13 registered13 users13

New Zealand Ministry of Health13 Pacific Health Resources

wwwhealthgovtnzour-shy‐workpopulationspacific-shy‐healthpacific-shy‐health-shy‐resources

The13 New13 Zealand13 Ministry13 of13 Health13 Pacific13 Health13 Resources13 webpage13 offers13 two13 types13 of13 resources13 publications13 and13 health13 education13 resources13 13

The13 publications13 section13 of13 the13 web13 page13 lists13 publications13 by13 year13 Most13 of13 these13 are13 New13 Zealandndashfocused13 However13 each13 link13 has13 a13 brief13 description13 which13 makes13 it13 easier13 to13 scan13 the13 long13 list13 to13 assess13 relevance13 An13 example13 of13 a13 report13 that13 might13 be13 relevant13 for13 community13 health13 workers13 is13 Customary13 tattooing13 guidelines13 for13 operators13 (also13 available13 in13 Samoan)13


5313

The13 education13 resources13 section13 of13 the13 webpage13 provides13 links13 to13 Pacific-shy‐focused13 pamphlets13 and13 posters13 translated13 into13 Samoan13 Tongan13 Niuean13 Cook13 Islands13 Mmacrˉaori13 Tuvalu13 Fijian13 and13 Tokelauan13 The13 resources13 are13 listed13 on13 the13 site13 by13 health13 issue13 breastfeeding13 breast13 screening13 cervical13 screening13 child13 health13 diabetes13 eatingfood13 immunisation13 meningitis13 pregnancy13 and13 sexual13 health13 Many13 of13 these13 resources13 such13 as13 immunisation13 options13 available13 are13 New13 Zealandndashfocused13 in13 their13 advice13 However13 the13 relatively13 simple13 descriptions13 and13 associated13 diagrams13 could13 help13 community13 health13 workers13 to13 understand13 health13 issues13 themselves13 or13 to13 explain13 to13 others13 The13 resources13 are13 the13 same13 as13 those13 in13 the13 New13 Zealand13 Ministry13 of13 Healthrsquos13 HealthEd13 website13 however13 this13 page13 provides13 a13 Pacific13 lens13 from13 which13 to13 find13 these13 re-shy‐sources13

Pacific Basin Telehealth Resource Center

httppbtrcorg13

The13 Pacific13 Basin13 Telehealth13 Resource13 Center13 aims13 to13 advance13 the13 development13 implementa-shy‐tion13 and13 integration13 of13 tele-shy‐health13 in13 the13 Pacific13 Basin13 The13 centre13 appears13 focused13 on13 those13 Pacific13 countries13 with13 links13 to13 the13 United13 States13 While13 one13 of13 the13 centrersquos13 aims13 is13 to13 share13 in-shy‐formation13 one13 author13 of13 this13 report13 who13 is13 considered13 highly13 digitally13 literate13 could13 not13 access13 resources13 from13 the13 websitersquos13 Resources13 page13 Presentations13 in13 the13 News13 section13 highlight13 community13 involvement13 and13 engagement13 as13 a13 key13 to13 success13 in13 the13 use13 of13 technology13 to13 sup-shy‐port13 health13 delivery13 Given13 the13 difficulty13 accessing13 resources13 it13 is13 hard13 to13 know13 how13 relevant13 material13 might13 be13 but13 the13 site13 seems13 unsuited13 to13 community13 health13 workers13 at13 present13

Pacific Health Dialog

wwwpacifichealthdialogorgfj13

Pacific13 Health13 Dialog13 is13 an13 online13 journal13 published13 specifically13 for13 Pacific13 countries13 It13 aims13 to13 improve13 health13 outcomes13 in13 the13 Pacific13 through13 better-shy‐informed13 Pacific13 health13 professionals13 and13 to13 engage13 the13 global13 community13 in13 dialogue13 on13 health13 in13 the13 Pacific13 Established13 in13 199413 the13 journal13 is13 published13 twice13 a13 year13 All13 issues13 are13 available13 from13 the13 website13 and13 each13 issue13 covers13 a13 different13 topic13 Content13 includes13 peer-shy‐reviewed13 original13 papers13 case13 reports13 com-shy‐munications13 viewpoints13 and13 opinions13 reviews13 and13 news13 from13 Pacific13 health13 institutions13 contributed13 by13 local13 and13 international13 health13 professionals13 In13 defining13 the13 scope13 of13 the13 journal13 the13 site13 does13 not13 mention13 community13 health13 workers13 for13 whom13 some13 of13 the13 articles13 would13 be13 relevant13 However13 they13 would13 need13 to13 sift13 through13 a13 large13 volume13 of13 irrelevant13 information13 to13 find13 the13 relevant13 parts13

Pacific Health Review

httppacifichealthreviewconz13 13

The13 Pacific13 Health13 Review13 supported13 by13 the13 New13 Zealand13 Ministry13 of13 Health13 is13 a13 quarterly13 pub-shy‐lication13 with13 the13 tag-shy‐line13 ldquoMaking13 education13 easyrdquo13 Each13 issue13 is13 an13 engaging13 PDF13 that13 can13 be13 downloaded13 free13 from13 the13 site13 and13 is13 a13 compilation13 of13 recent13 relevant13 Pacific13 research13 For13 each13 article13 the13 review13 gives13 the13 title13 authors13 a13 two-shy‐line13 summary13 commentary13 from13 a13 medi-shy‐cal13 researcher13 the13 formal13 reference13 and13 a13 link13 to13 the13 full13 article13 The13 review13 gives13 a13 quick13 not13 overly13 technical13 overview13 of13 recent13 research13 some13 of13 which13 may13 be13 of13 interest13 to13 community13 health13 workers13 (eg13 the13 effectiveness13 of13 storytelling13 in13 reducing13 blood13 pressure13 Samoan13 peo-shy‐plesrsquo13 views13 about13 antibiotics)13 The13 website13 gives13 users13 the13 option13 of13 receiving13 copies13 of13 the13 review13 by13 email13 when13 it13 is13 published13


5413

Pacific Health Voices

wwwpacifichealthvoicesorg13

Pacific13 Health13 Voices13 is13 an13 electronic13 health13 journal13 coordinated13 by13 the13 College13 of13 Medicine13 Nursing13 and13 Health13 Sciences13 at13 the13 Fiji13 National13 University13 (previously13 the13 Fiji13 School13 of13 Medi-shy‐cine)13 The13 journal13 aims13 to13 be13 the13 hub13 of13 health13 information13 for13 the13 Pacific13 by13 identifying13 and13 publishing13 the13 work13 of13 Pacific13 health13 workers13 and13 making13 it13 accessible13 to13 the13 rest13 of13 the13 Pacific13 and13 the13 world13 The13 mission13 includes13 improving13 peoplesrsquo13 health13

Many13 of13 the13 resources13 appear13 to13 be13 on13 topics13 that13 are13 less13 relevant13 for13 community13 health13 workers13 However13 some13 are13 relevant13 such13 as13 the13 Pacific13 Obesity13 Prevention13 in13 Communities13 Project13 (OPIC)13 Fiji13 Country13 Report13 (although13 one13 would13 need13 to13 be13 very13 interested13 to13 read13 the13 full13 110-shy‐page13 report)13 Including13 a13 brief13 version13 such13 as13 a13 two-shy‐page13 executive13 summary13 along13 with13 the13 full13 report13 would13 meet13 the13 needs13 of13 community13 health13 workers13 particularly13 if13 each13 resource13 appeared13 as13 a13 well-shy‐laid-shy‐out13 webpage13 rather13 than13 a13 file13 to13 download13 To13 make13 this13 site13 accessible13 to13 community13 health13 workers13 the13 resources13 would13 also13 need13 to13 be13 listed13 by13 topic13 rather13 than13 under13 headings13 related13 to13 their13 origin13 (eg13 reports13 other13 journals)13 This13 approach13 is13 used13 in13 the13 Archives13 section13 and13 makes13 it13 easier13 to13 find13 resources13 on13 a13 specific13 topic13 The13 ma-shy‐terial13 is13 relatively13 current13 with13 many13 resources13 dated13 201013 13

Pacific Human Resources for Health Alliance

wwwphrhaorg13

The13 Pacific13 Human13 Resources13 for13 Health13 Alliance13 works13 within13 the13 Pacific13 region13 to13 build13 human13 resource13 capacity13 for13 health13 It13 brings13 together13 national13 governments13 international13 agencies13 and13 other13 stakeholders13 in13 the13 health13 sector13 It13 is13 a13 member13 of13 the13 Global13 Health13 Workforce13 Alli-shy‐ance13 The13 alliance13 focuses13 on13 collecting13 and13 using13 reliable13 data13 improving13 health13 workforce13 planning13 and13 management13 and13 scaling13 up13 education13 and13 training13 of13 the13 health13 workforce13 to13 meet13 current13 shortages13 The13 site13 lists13 vacancies13 for13 many13 health13 professional13 roles13 but13 com-shy‐munity13 health13 worker13 roles13 are13 not13 included13 indicating13 that13 such13 roles13 are13 outside13 the13 scope13 of13 the13 site13

Pacific Open Learning Health Net (POLHN)

wwwpolhnorg13

This13 regional13 initiative13 is13 discussed13 in13 more13 detail13 earlier13 in13 the13 report13 The13 website13 provides13 links13 to13 the13 self-shy‐paced13 courses13 offered13 within13 POLHNrsquos13 learning13 management13 system13 These13 could13 be13 relevant13 for13 community13 health13 workers13 The13 courses13 cover13 patient13 safety13 computing13 skills13 risk13 management13 classifying13 diseases13 and13 treatment13 of13 Pacific-shy‐relevant13 diseases13 (eg13 diabetes13 mosquito-shy‐borne13 diseases13 HIVAIDS13 tuberculosis13 and13 sexually13 transmitted13 infections)13 POLHN13 estimates13 that13 each13 course13 will13 take13 12ndash2613 hours13 to13 complete13 and13 POLHN13 can13 sepa-shy‐rately13 assess13 these13 to13 give13 credit13 The13 website13 homepage13 has13 a13 clear13 link13 to13 helpdesk13 support13 for13 visitors13 to13 the13 site13

The13 POLHN13 website13 also13 provides13 links13 to13 formal13 tertiary13 providers13 of13 online13 health13 courses13 face-shy‐to-shy‐face13 short13 courses13 in13 the13 region13 and13 other13 organisations13 using13 self-shy‐paced13 eLearning13 to13 increase13 access13 to13 continuing13 professional13 development13 for13 health13 workers13 For13 example13 the13 American13 Global13 Health13 eLearning13 Center13 offers13 online13 self-shy‐paced13 courses13 at13 no13 charge13 Topics13 include13 family13 planning13 and13 reproductive13 health13 antenatal13 and13 newborn13 care13 child13 survival13 treating13 HIVAIDS13 and13 infectious13 diseases13 and13 health13 systems13 13


5513

Health13 professionals13 can13 use13 POLHNrsquos13 physical13 learning13 centres13 for13 Internet13 access13 and13 human13 support13

United Nations Family Planning Association Pacific Sub-Regional Office

httpcountryofficeunfpaorgpacific13

The13 United13 Nations13 Family13 Planning13 Association13 Pacific13 Sub-shy‐Regional13 Office13 website13 has13 a13 Re-shy‐sources13 page13 Many13 of13 the13 resources13 arranged13 by13 topic13 in13 the13 left-shy‐hand13 navigation13 bar13 are13 suitable13 for13 use13 by13 workers13 in13 the13 community13 Under13 ldquoUnderstand13 Reproductive13 Healthrdquo13 for13 example13 resources13 include13 a13 DVD13 available13 from13 the13 office13 evidence-shy‐based13 guidelines13 bro-shy‐chures13 and13 wall13 charts13 and13 Pacific13 country13 reports13 Other13 topics13 with13 similar13 resources13 include13 connecting13 with13 reproductive13 health13 commodity13 security13 talking13 about13 gender13 and13 preventing13 sexually13 transmitted13 infections13 The13 single13 resource13 for13 the13 topic13 ldquouse13 behaviour13 change13 com-shy‐municationrdquo13 is13 a13 toolkit13 targeted13 at13 programme13 managers13 that13 would13 also13 be13 helpful13 for13 those13 working13 closely13 in13 the13 community13 Each13 resource13 has13 an13 image13 and13 a13 brief13 description13 to13 help13 users13 assess13 relevance13

World Health Organization Western Pacific Region

13 wwwwprowhoint13

The13 Western13 Pacific13 Region13 of13 the13 World13 Health13 Organization13 website13 is13 well13 structured13 with13 a13 wealth13 of13 information13 publications13 and13 resources13 The13 link13 ldquoHealth13 topicsrdquo13 on13 the13 top13 navi-shy‐gation13 bar13 takes13 users13 to13 a13 page13 of13 topic13 links13 listed13 alphabetically13 Clicking13 on13 a13 link13 then13 takes13 users13 to13 a13 page13 of13 various13 resources13 classified13 under13 the13 following13 headings13 general13 information13 fact13 sheets13 news13 and13 press13 releases13 relevant13 publications13 and13 documents13 pol-shy‐icy13 documents13 meetings13 and13 events13 data13 collaborating13 centres13 and13 links13 On13 the13 Media13 centre13 page13 news13 items13 have13 the13 first13 line13 displayed13 and13 publications13 have13 an13 image13 and13 a13 brief13 description13 which13 also13 help13 users13 assess13 relevance13 The13 Multimedia13 link13 goes13 to13 an13 image13 bank13 and13 a13 list13 of13 videos13 which13 includes13 an13 instructional13 video13 on13 hand13 washing13 and13 advocacy13 videos13 on13 topics13 such13 as13 dengue13 However13 the13 information13 is13 targeted13 at13 policy13 makers13 rather13 than13 community13 health13 workers13 For13 example13 the13 fact13 sheets13 give13 country13 or13 regional13 statistics13 and13 comment13 on13 policy13 initiatives13 Community13 health13 workers13 would13 need13 to13 sift13 through13 a13 lot13 of13 information13 to13 find13 the13 small13 amount13 of13 information13 relevant13 to13 them13 and13 their13 communities13

13

13

13

13


PALE SAU NI AND TERRY NEAL

O PEN PO LYTECHNI C O F NEW ZEALAND

13

13

13

13

13

13

13

13

13

13

13

13

EDI TO R TRU DI V AN W YK

SEPTEMB ER 2012

13

13







13



13

13

13

13

13

13

Published13 by13




i13

Contents



Introduction 1



Phases 3




Scope9



Crucial role11

Keys to success12

The interviewees 14









ii13







Health literacy 34







Mobile learning43

Supervision 44


Conclusion44

References 46




13


iii13














iv13
















v13






vi13






























113











on13 team13 None13





None13




None13




213





Standard13





13









313




PHASES








Literature review










413


Interviews











513




Digital literacy










613


Health literacy







Digital health




713





















813













913






SCO PE















1013


13

13








1113






CRU CI AL RO LE






1213




K EYS TO SU CCESS








1313









1413












1513















1613






COUNTRY13


INHABITANTS13






13 200113 201013 200113 201013 200113 201013 200013 201013 Kiribati13 1813 9013 013 113 413 413 0413 1013

Nauru13 -shy‐13 6013 -shy‐13 413 1813 1813 1213 6013

PNG13 0813 1313 013 0113 113 213 0213 2813

Samoa13 0613 7013 013 0113 513 1913 113 9113

Solomon13 Islands13 0513 5013 013 0413 213 213 0313 613

Tonga13 2413 12013 013 113 1013 3013 0213 5213

Tuvalu13 5213 25013 013 313 713 1613 013 2513

Vanuatu13 2113 8013 013 0113 413 213 0213 11913

13

Australia13 46813 76013 0613 2313 5213 3913 4513 10113

New13 Zealand13 47413 83013 0113 2513 4713 4313 4013 11513

Fiji13 1513 14813 013 213 1113 1613 713 11613




1713










1813












1913












2013









2113












2213















2313











2413



















2513


Nauru13



Fiji13 13


Samoa13


Tuvalu13


Vanuatu13




2613




Kiribati13








13

13


2713



Solomon13 Islands13





Tonga13







2813












2913




















3013

DI STANCE LEARNI NG
















3113























3213












3313















3413






HEALTH LI TERACY




3513















3613












3713












3813














3913







13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13




4013








4113













4213












4313



DI STANCE LEARNI NG




MO B I LE LEARNI NG





4413






SU PERV I SI O N





CO NCLU SI O N






4513



4613


















4713

















4813
















4913















5013











13 13

13


5113



















5213













5313



httppbtrcorg13









5413






wwwphrhaorg13



wwwpolhnorg13




5513






13 wwwwprowhoint13


13

13

13







13



13

13

13

13

13

13

Published13 by13




i13

Contents



Introduction 1



Phases 3




Scope9



Crucial role11

Keys to success12

The interviewees 14









ii13







Health literacy 34







Mobile learning43

Supervision 44


Conclusion44

References 46




13


iii13














iv13
















v13






vi13






























113











on13 team13 None13





None13




None13




213





Standard13





13









313




PHASES








Literature review










413


Interviews











513




Digital literacy










613


Health literacy







Digital health




713





















813













913






SCO PE















1013


13

13








1113






CRU CI AL RO LE






1213




K EYS TO SU CCESS








1313









1413












1513















1613






COUNTRY13


INHABITANTS13






13 200113 201013 200113 201013 200113 201013 200013 201013 Kiribati13 1813 9013 013 113 413 413 0413 1013

Nauru13 -shy‐13 6013 -shy‐13 413 1813 1813 1213 6013

PNG13 0813 1313 013 0113 113 213 0213 2813

Samoa13 0613 7013 013 0113 513 1913 113 9113

Solomon13 Islands13 0513 5013 013 0413 213 213 0313 613

Tonga13 2413 12013 013 113 1013 3013 0213 5213

Tuvalu13 5213 25013 013 313 713 1613 013 2513

Vanuatu13 2113 8013 013 0113 413 213 0213 11913

13

Australia13 46813 76013 0613 2313 5213 3913 4513 10113

New13 Zealand13 47413 83013 0113 2513 4713 4313 4013 11513

Fiji13 1513 14813 013 213 1113 1613 713 11613




1713










1813












1913












2013









2113












2213















2313











2413



















2513


Nauru13



Fiji13 13


Samoa13


Tuvalu13


Vanuatu13




2613




Kiribati13








13

13


2713



Solomon13 Islands13





Tonga13







2813












2913




















3013

DI STANCE LEARNI NG
















3113























3213












3313















3413






HEALTH LI TERACY




3513















3613












3713












3813














3913







13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13




4013








4113













4213












4313



DI STANCE LEARNI NG




MO B I LE LEARNI NG





4413






SU PERV I SI O N





CO NCLU SI O N






4513



4613


















4713

















4813
















4913















5013











13 13

13


5113



















5213













5313



httppbtrcorg13









5413






wwwphrhaorg13



wwwpolhnorg13




5513






13 wwwwprowhoint13


13


i13

Contents



Introduction 1



Phases 3




Scope9



Crucial role11

Keys to success12

The interviewees 14









ii13







Health literacy 34







Mobile learning43

Supervision 44


Conclusion44

References 46




13


iii13














iv13
















v13






vi13






























113











on13 team13 None13





None13




None13




213





Standard13





13









313




PHASES








Literature review










413


Interviews











513




Digital literacy










613


Health literacy







Digital health




713





















813













913






SCO PE















1013


13

13








1113






CRU CI AL RO LE






1213




K EYS TO SU CCESS








1313









1413












1513















1613






COUNTRY13


INHABITANTS13






13 200113 201013 200113 201013 200113 201013 200013 201013 Kiribati13 1813 9013 013 113 413 413 0413 1013

Nauru13 -shy‐13 6013 -shy‐13 413 1813 1813 1213 6013

PNG13 0813 1313 013 0113 113 213 0213 2813

Samoa13 0613 7013 013 0113 513 1913 113 9113

Solomon13 Islands13 0513 5013 013 0413 213 213 0313 613

Tonga13 2413 12013 013 113 1013 3013 0213 5213

Tuvalu13 5213 25013 013 313 713 1613 013 2513

Vanuatu13 2113 8013 013 0113 413 213 0213 11913

13

Australia13 46813 76013 0613 2313 5213 3913 4513 10113

New13 Zealand13 47413 83013 0113 2513 4713 4313 4013 11513

Fiji13 1513 14813 013 213 1113 1613 713 11613




1713










1813












1913












2013









2113












2213















2313











2413



















2513


Nauru13



Fiji13 13


Samoa13


Tuvalu13


Vanuatu13




2613




Kiribati13








13

13


2713



Solomon13 Islands13





Tonga13







2813












2913




















3013

DI STANCE LEARNI NG
















3113























3213












3313















3413






HEALTH LI TERACY




3513















3613












3713












3813














3913







13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13




4013








4113













4213












4313



DI STANCE LEARNI NG




MO B I LE LEARNI NG





4413






SU PERV I SI O N





CO NCLU SI O N






4513



4613


















4713

















4813
















4913















5013











13 13

13


5113



















5213













5313



httppbtrcorg13









5413






wwwphrhaorg13



wwwpolhnorg13




5513






13 wwwwprowhoint13


13


ii13







Health literacy 34







Mobile learning43

Supervision 44


Conclusion44

References 46




13


iii13














iv13
















v13






vi13






























113











on13 team13 None13





None13




None13




213





Standard13





13









313




PHASES








Literature review










413


Interviews











513




Digital literacy










613


Health literacy







Digital health




713





















813













913






SCO PE















1013


13

13








1113






CRU CI AL RO LE






1213




K EYS TO SU CCESS








1313









1413












1513















1613






COUNTRY13


INHABITANTS13






13 200113 201013 200113 201013 200113 201013 200013 201013 Kiribati13 1813 9013 013 113 413 413 0413 1013

Nauru13 -shy‐13 6013 -shy‐13 413 1813 1813 1213 6013

PNG13 0813 1313 013 0113 113 213 0213 2813

Samoa13 0613 7013 013 0113 513 1913 113 9113

Solomon13 Islands13 0513 5013 013 0413 213 213 0313 613

Tonga13 2413 12013 013 113 1013 3013 0213 5213

Tuvalu13 5213 25013 013 313 713 1613 013 2513

Vanuatu13 2113 8013 013 0113 413 213 0213 11913

13

Australia13 46813 76013 0613 2313 5213 3913 4513 10113

New13 Zealand13 47413 83013 0113 2513 4713 4313 4013 11513

Fiji13 1513 14813 013 213 1113 1613 713 11613




1713










1813












1913












2013









2113












2213















2313











2413



















2513


Nauru13



Fiji13 13


Samoa13


Tuvalu13


Vanuatu13




2613




Kiribati13








13

13


2713



Solomon13 Islands13





Tonga13







2813












2913




















3013

DI STANCE LEARNI NG
















3113























3213












3313















3413






HEALTH LI TERACY




3513















3613












3713












3813














3913







13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13




4013








4113













4213












4313



DI STANCE LEARNI NG




MO B I LE LEARNI NG





4413






SU PERV I SI O N





CO NCLU SI O N






4513



4613


















4713

















4813
















4913















5013











13 13

13


5113



















5213













5313



httppbtrcorg13









5413






wwwphrhaorg13



wwwpolhnorg13




5513






13 wwwwprowhoint13


13


iii13














iv13
















v13






vi13






























113











on13 team13 None13





None13




None13




213





Standard13





13









313




PHASES








Literature review










413


Interviews











513




Digital literacy










613


Health literacy







Digital health




713





















813













913






SCO PE















1013


13

13








1113






CRU CI AL RO LE






1213




K EYS TO SU CCESS








1313









1413












1513















1613






COUNTRY13


INHABITANTS13






13 200113 201013 200113 201013 200113 201013 200013 201013 Kiribati13 1813 9013 013 113 413 413 0413 1013

Nauru13 -shy‐13 6013 -shy‐13 413 1813 1813 1213 6013

PNG13 0813 1313 013 0113 113 213 0213 2813

Samoa13 0613 7013 013 0113 513 1913 113 9113

Solomon13 Islands13 0513 5013 013 0413 213 213 0313 613

Tonga13 2413 12013 013 113 1013 3013 0213 5213

Tuvalu13 5213 25013 013 313 713 1613 013 2513

Vanuatu13 2113 8013 013 0113 413 213 0213 11913

13

Australia13 46813 76013 0613 2313 5213 3913 4513 10113

New13 Zealand13 47413 83013 0113 2513 4713 4313 4013 11513

Fiji13 1513 14813 013 213 1113 1613 713 11613




1713










1813












1913












2013









2113












2213















2313











2413



















2513


Nauru13



Fiji13 13


Samoa13


Tuvalu13


Vanuatu13




2613




Kiribati13








13

13


2713



Solomon13 Islands13





Tonga13







2813












2913




















3013

DI STANCE LEARNI NG
















3113























3213












3313















3413






HEALTH LI TERACY




3513















3613












3713












3813














3913







13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13




4013








4113













4213












4313



DI STANCE LEARNI NG




MO B I LE LEARNI NG





4413






SU PERV I SI O N





CO NCLU SI O N






4513



4613


















4713

















4813
















4913















5013











13 13

13


5113



















5213













5313



httppbtrcorg13









5413






wwwphrhaorg13



wwwpolhnorg13




5513






13 wwwwprowhoint13


13


iv13
















v13






vi13






























113











on13 team13 None13





None13




None13




213





Standard13





13









313




PHASES








Literature review










413


Interviews











513




Digital literacy










613


Health literacy







Digital health




713





















813













913






SCO PE















1013


13

13








1113






CRU CI AL RO LE






1213




K EYS TO SU CCESS








1313









1413












1513















1613






COUNTRY13


INHABITANTS13






13 200113 201013 200113 201013 200113 201013 200013 201013 Kiribati13 1813 9013 013 113 413 413 0413 1013

Nauru13 -shy‐13 6013 -shy‐13 413 1813 1813 1213 6013

PNG13 0813 1313 013 0113 113 213 0213 2813

Samoa13 0613 7013 013 0113 513 1913 113 9113

Solomon13 Islands13 0513 5013 013 0413 213 213 0313 613

Tonga13 2413 12013 013 113 1013 3013 0213 5213

Tuvalu13 5213 25013 013 313 713 1613 013 2513

Vanuatu13 2113 8013 013 0113 413 213 0213 11913

13

Australia13 46813 76013 0613 2313 5213 3913 4513 10113

New13 Zealand13 47413 83013 0113 2513 4713 4313 4013 11513

Fiji13 1513 14813 013 213 1113 1613 713 11613




1713










1813












1913












2013









2113












2213















2313











2413



















2513


Nauru13



Fiji13 13


Samoa13


Tuvalu13


Vanuatu13




2613




Kiribati13








13

13


2713



Solomon13 Islands13





Tonga13







2813












2913




















3013

DI STANCE LEARNI NG
















3113























3213












3313















3413






HEALTH LI TERACY




3513















3613












3713












3813














3913







13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13




4013








4113













4213












4313



DI STANCE LEARNI NG




MO B I LE LEARNI NG





4413






SU PERV I SI O N





CO NCLU SI O N






4513



4613


















4713

















4813
















4913















5013











13 13

13


5113



















5213













5313



httppbtrcorg13









5413






wwwphrhaorg13



wwwpolhnorg13




5513






13 wwwwprowhoint13


13


v13






vi13






























113











on13 team13 None13





None13




None13




213





Standard13





13









313




PHASES








Literature review










413


Interviews











513




Digital literacy










613


Health literacy







Digital health




713





















813













913






SCO PE















1013


13

13








1113






CRU CI AL RO LE






1213




K EYS TO SU CCESS








1313









1413












1513















1613






COUNTRY13


INHABITANTS13






13 200113 201013 200113 201013 200113 201013 200013 201013 Kiribati13 1813 9013 013 113 413 413 0413 1013

Nauru13 -shy‐13 6013 -shy‐13 413 1813 1813 1213 6013

PNG13 0813 1313 013 0113 113 213 0213 2813

Samoa13 0613 7013 013 0113 513 1913 113 9113

Solomon13 Islands13 0513 5013 013 0413 213 213 0313 613

Tonga13 2413 12013 013 113 1013 3013 0213 5213

Tuvalu13 5213 25013 013 313 713 1613 013 2513

Vanuatu13 2113 8013 013 0113 413 213 0213 11913

13

Australia13 46813 76013 0613 2313 5213 3913 4513 10113

New13 Zealand13 47413 83013 0113 2513 4713 4313 4013 11513

Fiji13 1513 14813 013 213 1113 1613 713 11613




1713










1813












1913












2013









2113












2213















2313











2413



















2513


Nauru13



Fiji13 13


Samoa13


Tuvalu13


Vanuatu13




2613




Kiribati13








13

13


2713



Solomon13 Islands13





Tonga13







2813












2913




















3013

DI STANCE LEARNI NG
















3113























3213












3313















3413






HEALTH LI TERACY




3513















3613












3713












3813














3913







13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13 13




4013








4113













4213












4313



DI STANCE LEARNI NG




MO B I LE LEARNI NG





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